breech presentation vertex

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Breech Births

In the last weeks of pregnancy, a baby usually moves so his or her head is positioned to come out of the vagina first during birth. This is called a vertex presentation. A breech presentation occurs when the baby’s buttocks, feet, or both are positioned to come out first during birth. This happens in 3–4% of full-term births.

What are the different types of breech birth presentations?

Complete breech: Here, the buttocks are pointing downward with the legs folded at the knees and feet near the buttocks.
Frank breech: In this position, the baby’s buttocks are aimed at the birth canal with its legs sticking straight up in front of his or her body and the feet near the head.
Footling breech: In this position, one or both of the baby’s feet point downward and will deliver before the rest of the body.

What causes a breech presentation?

The causes of breech presentations are not fully understood. However, the data show that breech birth is more common when:

You have been pregnant before
In pregnancies of multiples
When there is a history of premature delivery
When the uterus has too much or too little amniotic fluid
When there is an abnormally shaped uterus or a uterus with abnormal growths, such as fibroids
The placenta covers all or part of the opening of the uterus placenta previa

How is a breech presentation diagnosed?

A few weeks prior to the due date, the health care provider will place her hands on the mother’s lower abdomen to locate the baby’s head, back, and buttocks. If it appears that the baby might be in a breech position, they can use ultrasound or pelvic exam to confirm the position. Special x-rays can also be used to determine the baby’s position and the size of the pelvis to determine if a vaginal delivery of a breech baby can be safely attempted.

Can a breech presentation mean something is wrong?

Even though most breech babies are born healthy, there is a slightly elevated risk for certain problems. Birth defects are slightly more common in breech babies and the defect might be the reason that the baby failed to move into the right position prior to delivery.

Can a breech presentation be changed?

It is preferable to try to turn a breech baby between the 32nd and 37th weeks of pregnancy . The methods of turning a baby will vary and the success rate for each method can also vary. It is best to discuss the options with the health care provider to see which method she recommends.

Medical Techniques

External Cephalic Version (EVC) is a non-surgical technique to move the baby in the uterus. In this procedure, a medication is given to help relax the uterus. There might also be the use of an ultrasound to determine the position of the baby, the location of the placenta and the amount of amniotic fluid in the uterus.

Gentle pushing on the lower abdomen can turn the baby into the head-down position. Throughout the external version the baby’s heartbeat will be closely monitored so that if a problem develops, the health care provider will immediately stop the procedure. ECV usually is done near a delivery room so if a problem occurs, a cesarean delivery can be performed quickly. The external version has a high success rate and can be considered if you have had a previous cesarean delivery.

ECV will not be tried if:

You are carrying more than one fetus
There are concerns about the health of the fetus
You have certain abnormalities of the reproductive system
The placenta is in the wrong place
The placenta has come away from the wall of the uterus ( placental abruption )

Complications of EVC include:

Prelabor rupture of membranes
Changes in the fetus’s heart rate
Placental abruption
Preterm labor

Vaginal delivery versus cesarean for breech birth?

Most health care providers do not believe in attempting a vaginal delivery for a breech position. However, some will delay making a final decision until the woman is in labor. The following conditions are considered necessary in order to attempt a vaginal birth:

The baby is full-term and in the frank breech presentation
The baby does not show signs of distress while its heart rate is closely monitored.
The process of labor is smooth and steady with the cervix widening as the baby descends.
The health care provider estimates that the baby is not too big or the mother’s pelvis too narrow for the baby to pass safely through the birth canal.
Anesthesia is available and a cesarean delivery possible on short notice

What are the risks and complications of a vaginal delivery?

In a breech birth, the baby’s head is the last part of its body to emerge making it more difficult to ease it through the birth canal. Sometimes forceps are used to guide the baby’s head out of the birth canal. Another potential problem is cord prolapse . In this situation the umbilical cord is squeezed as the baby moves toward the birth canal, thus slowing the baby’s supply of oxygen and blood. In a vaginal breech delivery, electronic fetal monitoring will be used to monitor the baby’s heartbeat throughout the course of labor. Cesarean delivery may be an option if signs develop that the baby may be in distress.

When is a cesarean delivery used with a breech presentation?

Most health care providers recommend a cesarean delivery for all babies in a breech position, especially babies that are premature. Since premature babies are small and more fragile, and because the head of a premature baby is relatively larger in proportion to its body, the baby is unlikely to stretch the cervix as much as a full-term baby. This means that there might be less room for the head to emerge.

Want to Know More?

Creating Your Birth Plan
Labor & Birth Terms to Know
Cesarean Birth After Care

Compiled using information from the following sources:

ACOG: If Your Baby is Breech
William’s Obstetrics Twenty-Second Ed. Cunningham, F. Gary, et al, Ch. 24.
Danforth’s Obstetrics and Gynecology Ninth Ed. Scott, James R., et al, Ch. 21.

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Fetal Presentation, Position, and Lie (Including Breech Presentation)

Variations in Fetal Position and Presentation |

During pregnancy, the fetus can be positioned in many different ways inside the mother's uterus. The fetus may be head up or down or facing the mother's back or front. At first, the fetus can move around easily or shift position as the mother moves. Toward the end of the pregnancy the fetus is larger, has less room to move, and stays in one position. How the fetus is positioned has an important effect on delivery and, for certain positions, a cesarean delivery is necessary. There are medical terms that describe precisely how the fetus is positioned, and identifying the fetal position helps doctors to anticipate potential difficulties during labor and delivery.

Presentation refers to the part of the fetus’s body that leads the way out through the birth canal (called the presenting part). Usually, the head leads the way, but sometimes the buttocks (breech presentation), shoulder, or face leads the way.

Position refers to whether the fetus is facing backward (occiput anterior) or forward (occiput posterior). The occiput is a bone at the back of the baby's head. Therefore, facing backward is called occiput anterior (facing the mother’s back and facing down when the mother lies on her back). Facing forward is called occiput posterior (facing toward the mother's pubic bone and facing up when the mother lies on her back).

Lie refers to the angle of the fetus in relation to the mother and the uterus. Up-and-down (with the baby's spine parallel to mother's spine, called longitudinal) is normal, but sometimes the lie is sideways (transverse) or at an angle (oblique).

For these aspects of fetal positioning, the combination that is the most common, safest, and easiest for the mother to deliver is the following:

Head first (called vertex or cephalic presentation)

Facing backward (occiput anterior position)

Spine parallel to mother's spine (longitudinal lie)

Neck bent forward with chin tucked

Arms folded across the chest

If the fetus is in a different position, lie, or presentation, labor may be more difficult, and a normal vaginal delivery may not be possible.

Variations in fetal presentation, position, or lie may occur when

The fetus is too large for the mother's pelvis (fetopelvic disproportion).

The uterus is abnormally shaped or contains growths such as fibroids .

The fetus has a birth defect .

There is more than one fetus (multiple gestation).

Position and Presentation of the Fetus

Toward the end of pregnancy, the fetus moves into position for delivery. Normally, the presentation is vertex (head first), and the position is occiput anterior (facing toward the pregnant person's spine) and with the face and body angled to one side and the neck flexed.

Variations in fetal presentations include face, brow, breech, and shoulder. Occiput posterior position (facing forward, toward the mother's pubic bone) is less common than occiput anterior position (facing backward, toward the mother's spine).

Variations in Fetal Position and Presentation

Some variations in position and presentation that make delivery difficult occur frequently.

Occiput posterior position

In occiput posterior position (sometimes called sunny-side up), the fetus is head first (vertex presentation) but is facing forward (toward the mother's pubic bone—that is, facing up when the mother lies on her back). This is a very common position that is not abnormal, but it makes delivery more difficult than when the fetus is in the occiput anterior position (facing toward the mother's spine—that is facing down when the mother lies on her back).

When a fetus faces up, the neck is often straightened rather than bent,which requires more room for the head to pass through the birth canal. Delivery assisted by a vacuum device or forceps or cesarean delivery may be necessary.

Breech presentation

In breech presentation, the baby's buttocks or sometimes the feet are positioned to deliver first (before the head).

When delivered vaginally, babies that present buttocks first are more at risk of injury or even death than those that present head first.

The reason for the risks to babies in breech presentation is that the baby's hips and buttocks are not as wide as the head. Therefore, when the hips and buttocks pass through the cervix first, the passageway may not be wide enough for the head to pass through. In addition, when the head follows the buttocks, the neck may be bent slightly backwards. The neck being bent backward increases the width required for delivery as compared to when the head is angled forward with the chin tucked, which is the position that is easiest for delivery. Thus, the baby’s body may be delivered and then the head may get caught and not be able to pass through the birth canal. When the baby’s head is caught, this puts pressure on the umbilical cord in the birth canal, so that very little oxygen can reach the baby. Brain damage due to lack of oxygen is more common among breech babies than among those presenting head first.

In a first delivery, these problems may occur more frequently because a woman’s tissues have not been stretched by previous deliveries. Because of risk of injury or even death to the baby, cesarean delivery is preferred when the fetus is in breech presentation, unless the doctor is very experienced with and skilled at delivering breech babies or there is not an adequate facility or equipment to safely perform a cesarean delivery.

Breech presentation is more likely to occur in the following circumstances:

Labor starts too soon (preterm labor).

The uterus is abnormally shaped or contains abnormal growths such as fibroids .

If Your Baby Is Breech

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Frequently Asked Questions Expand All

In the last weeks of pregnancy, a fetus usually moves so his or her head is positioned to come out of the vagina first during birth. This is called a vertex presentation . A breech presentation occurs when the fetus’s buttocks, feet, or both are in place to come out first during birth. This happens in 3–4% of full-term births.

It is not always known why a fetus is breech. Some factors that may contribute to a fetus being in a breech presentation include the following:

You have been pregnant before.

There is more than one fetus in the uterus (twins or more).

There is too much or too little amniotic fluid .

The uterus is not normal in shape or has abnormal growths such as fibroids .

The placenta covers all or part of the opening of the uterus ( placenta previa )

The fetus is preterm .

Occasionally fetuses with certain birth defects will not turn into the head-down position before birth. However, most fetuses in a breech presentation are otherwise normal.

Your health care professional may be able to tell which way your fetus is facing by placing his or her hands at certain points on your abdomen. By feeling where the fetus's head, back, and buttocks are, it may be possible to find out what part of the fetus is presenting first. An ultrasound exam or pelvic exam may be used to confirm it.

External cephalic version (ECV) is an attempt to turn the fetus so that he or she is head down. ECV can improve your chance of having a vaginal birth. If the fetus is breech and your pregnancy is greater than 36 weeks your health care professional may suggest ECV.

ECV will not be tried if:

You are carrying more than one fetus

There are concerns about the health of the fetus

You have certain abnormalities of the reproductive system

The placenta is in the wrong place

The placenta has come away from the wall of the uterus ( placental abruption )

ECV can be considered if you have had a previous cesarean delivery .

The health care professional performs ECV by placing his or her hands on your abdomen. Firm pressure is applied to the abdomen so that the fetus rolls into a head-down position. Two people may be needed to perform ECV. Ultrasound also may be used to help guide the turning.

The fetus's heart rate is checked with fetal monitoring before and after ECV. If any problems arise with you or the fetus, ECV will be stopped right away. ECV usually is done near a delivery room. If a problem occurs, a cesarean delivery can be performed quickly, if necessary.

Complications may include the following:

Prelabor rupture of membranes

Changes in the fetus's heart rate

Placental abruption

Preterm labor

More than one half of attempts at ECV succeed. However, some fetuses who are successfully turned with ECV move back into a breech presentation. If this happens, ECV may be tried again. ECV tends to be harder to do as the time for birth gets closer. As the fetus grows bigger, there is less room for him or her to move.

Most fetuses that are breech are born by planned cesarean delivery. A planned vaginal birth of a single breech fetus may be considered in some situations. Both vaginal birth and cesarean birth carry certain risks when a fetus is breech. However, the risk of complications is higher with a planned vaginal delivery than with a planned cesarean delivery.

In a breech presentation, the body comes out first, leaving the baby’s head to be delivered last. The baby’s body may not stretch the cervix enough to allow room for the baby’s head to come out easily. There is a risk that the baby’s head or shoulders may become wedged against the bones of the mother’s pelvis. Another problem that can happen during a vaginal breech birth is a prolapsed umbilical cord . It can slip into the vagina before the baby is delivered. If there is pressure put on the cord or it becomes pinched, it can decrease the flow of blood and oxygen through the cord to the baby.

Although a planned cesarean birth is the most common way that breech fetuses are born, there may be reasons to try to avoid a cesarean birth.

A cesarean delivery is major surgery. Complications may include infection, bleeding, or injury to internal organs.

The type of anesthesia used sometimes causes problems.

Having a cesarean delivery also can lead to serious problems in future pregnancies, such as rupture of the uterus and complications with the placenta.

With each cesarean delivery, these risks increase.

If you are thinking about having a vaginal birth and your fetus is breech, your health care professional will review the risks and benefits of vaginal birth and cesarean birth in detail. You usually need to meet certain guidelines specific to your hospital. The experience of your health care professional in delivering breech babies vaginally also is an important factor.

Amniotic Fluid : Fluid in the sac that holds the fetus.

Anesthesia : Relief of pain by loss of sensation.

Breech Presentation : A position in which the feet or buttocks of the fetus would appear first during birth.

Cervix : The lower, narrow end of the uterus at the top of the vagina.

Cesarean Delivery : Delivery of a fetus from the uterus through an incision made in the woman’s abdomen.

External Cephalic Version (ECV) : A technique, performed late in pregnancy, in which the doctor attempts to manually move a breech baby into the head-down position.

Fetus : The stage of human development beyond 8 completed weeks after fertilization.

Fibroids : Growths that form in the muscle of the uterus. Fibroids usually are noncancerous.

Oxygen : An element that we breathe in to sustain life.

Pelvic Exam : A physical examination of a woman’s pelvic organs.

Placenta : Tissue that provides nourishment to and takes waste away from the fetus.

Placenta Previa : A condition in which the placenta covers the opening of the uterus.

Placental Abruption : A condition in which the placenta has begun to separate from the uterus before the fetus is born.

Prelabor Rupture of Membranes : Rupture of the amniotic membranes that happens before labor begins. Also called premature rupture of membranes (PROM).

Preterm : Less than 37 weeks of pregnancy.

Ultrasound Exam : A test in which sound waves are used to examine inner parts of the body. During pregnancy, ultrasound can be used to check the fetus.

Umbilical Cord : A cord-like structure containing blood vessels. It connects the fetus to the placenta.

Uterus : A muscular organ in the female pelvis. During pregnancy, this organ holds and nourishes the fetus.

Vagina : A tube-like structure surrounded by muscles. The vagina leads from the uterus to the outside of the body.

Vertex Presentation : A presentation of the fetus where the head is positioned down.

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If you have further questions, contact your ob-gyn.

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Published: January 2019

Last reviewed: August 2022

Copyright 2024 by the American College of Obstetricians and Gynecologists. All rights reserved. Read copyright and permissions information . This information is designed as an educational aid for the public. It offers current information and opinions related to women's health. It is not intended as a statement of the standard of care. It does not explain all of the proper treatments or methods of care. It is not a substitute for the advice of a physician. Read ACOG’s complete disclaimer .

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Fetal presentation before birth

The way a baby is positioned in the uterus just before birth can have a big effect on labor and delivery. This positioning is called fetal presentation.

Babies twist, stretch and tumble quite a bit during pregnancy. Before labor starts, however, they usually come to rest in a way that allows them to be delivered through the birth canal headfirst. This position is called cephalic presentation. But there are other ways a baby may settle just before labor begins.

Following are some of the possible ways a baby may be positioned at the end of pregnancy.

Head down, face down

When a baby is head down, face down, the medical term for it is the cephalic occiput anterior position. This the most common position for a baby to be born in. With the face down and turned slightly to the side, the smallest part of the baby's head leads the way through the birth canal. It is the easiest way for a baby to be born.

Head down, face up

When a baby is head down, face up, the medical term for it is the cephalic occiput posterior position. In this position, it might be harder for a baby's head to go under the pubic bone during delivery. That can make labor take longer.

Most babies who begin labor in this position eventually turn to be face down. If that doesn't happen, and the second stage of labor is taking a long time, a member of the health care team may reach through the vagina to help the baby turn. This is called manual rotation.

In some cases, a baby can be born in the head-down, face-up position. Use of forceps or a vacuum device to help with delivery is more common when a baby is in this position than in the head-down, face-down position. In some cases, a C-section delivery may be needed.

Illustration of the head-down, face-up position

Frank breech

When a baby's feet or buttocks are in place to come out first during birth, it's called a breech presentation. This happens in about 3% to 4% of babies close to the time of birth. The baby shown below is in a frank breech presentation. That's when the knees aren't bent, and the feet are close to the baby's head. This is the most common type of breech presentation.

If you are more than 36 weeks into your pregnancy and your baby is in a frank breech presentation, your health care professional may try to move the baby into a head-down position. This is done using a procedure called external cephalic version. It involves one or two members of the health care team putting pressure on your belly with their hands to get the baby to roll into a head-down position.

If the procedure isn't successful, or if the baby moves back into a breech position, talk with a member of your health care team about the choices you have for delivery. Most babies in a frank breech position are born by planned C-section.

Illustration of the frank breech position

Complete and incomplete breech

A complete breech presentation, as shown below, is when the baby has both knees bent and both legs pulled close to the body. In an incomplete breech, one or both of the legs are not pulled close to the body, and one or both of the feet or knees are below the baby's buttocks. If a baby is in either of these positions, you might feel kicking in the lower part of your belly.

If you are more than 36 weeks into your pregnancy and your baby is in a complete or incomplete breech presentation, your health care professional may try to move the baby into a head-down position. This is done using a procedure called external cephalic version. It involves one or two members of the health care team putting pressure on your belly with their hands to get the baby to roll into a head-down position.

If the procedure isn't successful, or if the baby moves back into a breech position, talk with a member of your health care team about the choices you have for delivery. Many babies in a complete or incomplete breech position are born by planned C-section.

Illustration of a complete breech presentation

When a baby is sideways — lying horizontal across the uterus, rather than vertical — it's called a transverse lie. In this position, the baby's back might be:

Down, with the back facing the birth canal.
Sideways, with one shoulder pointing toward the birth canal.
Up, with the hands and feet facing the birth canal.

Although many babies are sideways early in pregnancy, few stay this way when labor begins.

If your baby is in a transverse lie during week 37 of your pregnancy, your health care professional may try to move the baby into a head-down position. This is done using a procedure called external cephalic version. External cephalic version involves one or two members of your health care team putting pressure on your belly with their hands to get the baby to roll into a head-down position.

If the procedure isn't successful, or if the baby moves back into a transverse lie, talk with a member of your health care team about the choices you have for delivery. Many babies who are in a transverse lie are born by C-section.

If you're pregnant with twins and only the twin that's lower in the uterus is head down, as shown below, your health care provider may first deliver that baby vaginally.

Then, in some cases, your health care team may suggest delivering the second twin in the breech position. Or they may try to move the second twin into a head-down position. This is done using a procedure called external cephalic version. External cephalic version involves one or two members of the health care team putting pressure on your belly with their hands to get the baby to roll into a head-down position.

Your health care team may suggest delivery by C-section for the second twin if:

An attempt to deliver the baby in the breech position is not successful.
You do not want to try to have the baby delivered vaginally in the breech position.
An attempt to move the baby into a head-down position is not successful.
You do not want to try to move the baby to a head-down position.

In some cases, your health care team may advise that you have both twins delivered by C-section. That might happen if the lower twin is not head down, the second twin has low or high birth weight as compared to the first twin, or if preterm labor starts.

Landon MB, et al., eds. Normal labor and delivery. In: Gabbe's Obstetrics: Normal and Problem Pregnancies. 8th ed. Elsevier; 2021. https://www.clinicalkey.com. Accessed May 19, 2023.
Holcroft Argani C, et al. Occiput posterior position. https://www.updtodate.com/contents/search. Accessed May 19, 2023.
Frequently asked questions: If your baby is breech. American College of Obstetricians and Gynecologists https://www.acog.org/womens-health/faqs/if-your-baby-is-breech. Accessed May 22, 2023.
Hofmeyr GJ. Overview of breech presentation. https://www.updtodate.com/contents/search. Accessed May 22, 2023.
Strauss RA, et al. Transverse fetal lie. https://www.updtodate.com/contents/search. Accessed May 22, 2023.
Chasen ST, et al. Twin pregnancy: Labor and delivery. https://www.updtodate.com/contents/search. Accessed May 22, 2023.
Cohen R, et al. Is vaginal delivery of a breech second twin safe? A comparison between delivery of vertex and non-vertex second twins. The Journal of Maternal-Fetal & Neonatal Medicine. 2021; doi:10.1080/14767058.2021.2005569.
Marnach ML (expert opinion). Mayo Clinic. May 31, 2023.

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Breech presentation

Learning objectives.

Types of breech presentation
Management of breech presentation

Definition and mechanisms

Breech presentation refers to the fetus in the longitudinal lie with the buttocks or lower extremity entering the pelvis first
Frank breech: fetus has flexion of both hips, and the legs are straight with the feet near the fetal face, in a pike position
Complete breech: fetus sits with flexion of both hips and both legs in a tuck position
Incomplete breech: can have any combination of one or both hips extended, also known as footling (one leg extended) breech, or double footling breech (both legs extended)
A higher percentage of breech presentations occurs with less advanced gestational age
At 32 weeks, 7% of fetuses are breech
At 28 weeks or less, 25% are breech
Clinical conditions associated with a breech presentation include those that may increase or decrease fetal motility, or affect the vertical polarity of the uterine cavity
It is unsafe for a breech baby to be born vaginally due to the risk of injury (dislocated or broken bones) or umbilical cord problems (flattening or twisting)
Turning the baby into the head-first position and/or a planned C-section are the safest option
Prematurity
Multiple gestations
Aneuploidies
Congenital anomalies: fetal sacrococcygeal teratoma, fetal thyroid goiter
Mullerian anomalies
Uterine leiomyoma
Placental polarity as in placenta previa
Polyhydramnios
Oligohydramnios
Previous history of breech presentation (recurrence rate is 10% for the second pregnancy and 27% in the third pregnancy)
Physical exam: palpation of a hard, round, mobile structure at the fundus and the inability to palpate a presenting part in the lower abdomen superior to the pubic bone or the engaged breach in the same area, should raise suspicion of a breech presentation
Cervical exam: the lack of a palpable presenting part, palpation of a lower extremity, usually a foot, or for the engaged breech, palpation of the soft tissue of the fetal buttocks may be noted
Note that the soft tissue of the fetal buttocks may be interpreted as caput of the fetal vertex if the patient has been laboring
Ultrasound confirms the diagnosis

Breech presentation, CTG, external cephalic version (ECV), vaginal breech, ceasarean delivery

What to Know About the Vertex Position

When you give birth, your baby usually comes out headfirst, also called the vertex position. In the weeks before you give birth, your baby will move to place their head above your vagina .

Your baby could also try to come out feet -first, bottom-first, or both feet- and bottom-first. This is the breech position and only happens in about 3% to 4% of births. Your baby could also be in transverse position if they’re sideways inside of you. If your baby is in breech position or transverse position, your doctor will talk to you about different options that you have to give birth.

Birth in Vertex Position

Before you give birth, your baby will change positions inside of you. But when labor begins, babies usually move into the vertex position.

They will move farther down to the opening of your vagina . The doctor or midwife will instruct you on pushing your baby until their head is almost ready to come out. You'll take long, deep breaths to oxygenate the baby. A slow birth of your baby’s head will also help stretch the skin and muscles around your vagina.

Other Positions Your Baby Can Be In

Breech position. If your baby is still in the breech position at 36 weeks of pregnancy , your doctor may offer you an external cephalic version (ECV), which is where a doctor puts pressure on your uterus to try to turn your baby to a headfirst position. It may be slightly uncomfortable or even painful, but it’s generally a safe way to help your baby reach the vertex position. ECV helps babies get to a headfirst position about 50% of the time.

You shouldn’t have an ECV if you have had recent bleeding from your vagina, if your baby’s heartbeat is abnormal, if your water is broken, or if you’re pregnant with more than one baby.

If ECV doesn’t work, you’ll either have a cesarean section (C-section), which is when a baby is delivered through a cut in the uterus and abdomen , or a vaginal breech birth.

It may not be safe to have a vaginal breech birth if your baby’s feet are under their bottom, your baby is bigger or smaller than average, your baby is in an odd position, you have a low placenta , or you have preeclampsia , which is when you have high blood pressure and damage to organs with pregnancy.

Transverse position. If your baby is laying sideways across your uterus close to the time of delivery, your doctor would offer an ECV or C-section.

Your doctors may be able to turn your baby to a headfirst position, but if they can’t or you begin labor before they can turn your baby, you’ll most likely have a C-section.

Risks of Breech and Transverse Position

ECV problems. If your baby isn’t in vertex position and your doctor uses ECV to move them, some problems can happen. Your amniotic sac, or the part that holds liquid during pregnancy, can break early, your baby’s heart rate may change, your placenta may pull apart from your uterus, or you could go into labor too early.

Your baby may also move back into a breech position once your doctor moves them into vertex position. Your doctor can try to move them again, but this gets harder as the baby gets bigger.

Breech birth problems. If you give birth in the breech position, your baby’s body may not be able to stretch your cervix enough for their head to come out. Your baby’s shoulders or head could get stuck against your pelvis.

Breech births can also cause your umbilical cord to go into your vagina before your baby does. This is an emergency and requires an immediate C-section.

C-section problems. Since this is a major surgery, infections, bleeding, and organ damage can happen. C-sections can also cause you to have issues with later pregnancies, such as a tear in your uterus or issues with your placenta.

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Labor & Delivery

What Causes Breech Presentation?

Learn more about the types, causes, and risks of breech presentation, along with how breech babies are typically delivered.

What Is Breech Presentation?

Types of breech presentation, what causes a breech baby, can you turn a breech baby, how are breech babies delivered.

FatCamera/Getty Images

Toward the end of pregnancy, your baby will start to get into position for delivery, with their head pointed down toward the vagina. This is otherwise known as vertex presentation. However, some babies turn inside the womb so that their feet or buttocks are poised to be delivered first, which is commonly referred to as breech presentation, or a breech baby.

As you near the end of your pregnancy journey, an OB-GYN or health care provider will check your baby's positioning. You might find yourself wondering: What causes breech presentation? Are there risks involved? And how are breech babies delivered? We turned to experts and research to answer some of the most common questions surrounding breech presentation, along with what causes this positioning in the first place.

During your pregnancy, your baby constantly moves around the uterus. Indeed, most babies do somersaults up until the 36th week of pregnancy , when they pick their final position in the womb, says Laura Riley , MD, an OB-GYN in New York City. Approximately 3-4% of babies end up “upside-down” in breech presentation, with their feet or buttocks near the cervix.

Breech presentation is typically diagnosed during a visit to an OB-GYN, midwife, or health care provider. Your physician can feel the position of your baby's head through your abdominal wall—or they can conduct a vaginal exam if your cervix is open. A suspected breech presentation should ultimately be confirmed via an ultrasound, after which you and your provider would have a discussion about delivery options, potential issues, and risks.

There are three types of breech babies: frank, footling, and complete. Learn about the differences between these breech presentations.

Frank Breech

With frank breech presentation, your baby’s bottom faces the cervix and their legs are straight up. This is the most common type of breech presentation.

Footling Breech

Like its name suggests, a footling breech is when one (single footling) or both (double footling) of the baby's feet are in the birth canal, where they’re positioned to be delivered first .

Complete Breech

In a complete breech presentation, baby’s bottom faces the cervix. Their legs are bent at the knees, and their feet are near their bottom. A complete breech is the least common type of breech presentation.

StatPearls [Internet].

Delivery, face and brow presentation.

Julija Makajeva ; Mohsina Ashraf .

Affiliations

Last Update: January 9, 2023 .

Continuing Education Activity

Face and brow presentation is a malpresentation during labor when the presenting part is either the face or, in the case of brow presentation, it is the area between the orbital ridge and the anterior fontanelle. This activity reviews the evaluation and management of these two presentations and explains the role of the interprofessional team in managing delivery safely for both the mother and the baby.

Describe the mechanism of labor in the face and brow presentation.
Summarize potential maternal and fetal complications during the face and brow presentations.
Review different management approaches for the face and brow presentation.
Outline some interprofessional strategies that will improve patient outcomes in delivery cases with face and brow presentation issues.
Introduction

The term presentation describes the leading part of the fetus or the anatomical structure closest to the maternal pelvic inlet during labor. The presentation can roughly be divided into the following classifications: cephalic, breech, shoulder, and compound. Cephalic presentation is the most common and can be further subclassified as vertex, sinciput, brow, face, and chin. The most common presentation in term labor is the vertex, where the fetal neck is flexed to the chin, minimizing the head circumference.

Face presentation – an abnormal form of cephalic presentation where the presenting part is mentum. This typically occurs because of hyperextension of the neck and the occiput touching the fetal back. Incidence of face presentation is rare, accounting for approximately 1 in 600 of all presentations. [1] [2] [3]

In brow presentation, the neck is not extended as much as in face presentation, and the leading part is the area between the anterior fontanelle and the orbital ridges. Brow presentation is considered the rarest of all malpresentation with a prevalence of 1 in 500 to 1 in 4000 deliveries. [3]

Both face and brow presentations occur due to extension of the fetal neck instead of flexion; therefore, conditions that would lead to hyperextension or prevent flexion of the fetal neck can all contribute to face or brow presentation. These risk factors may be related to either the mother or the fetus. Maternal risk factors are preterm delivery, contracted maternal pelvis, platypelloid pelvis, multiparity, previous cesarean section, black race. Fetal risk factors include anencephaly, multiple loops of cord around the neck, masses of the neck, macrosomia, polyhydramnios. [2] [4] [5]

These malpresentations are usually diagnosed during the second stage of labor when performing a digital examination. It is possible to palpate orbital ridges, nose, malar eminences, mentum, mouth, gums, and chin in face presentation. Based on the position of the chin, face presentation can be further divided into mentum anterior, posterior, or transverse. In brow presentation, anterior fontanelle and face can be palpated except for the mouth and the chin. Brow presentation can then be further described based on the position of the anterior fontanelle as frontal anterior, posterior, or transverse.

Diagnosing the exact presentation can be challenging, and face presentation may be misdiagnosed as frank breech. To avoid any confusion, a bedside ultrasound scan can be performed. [6] The ultrasound imaging can show a reduced angle between the occiput and the spine or, the chin is separated from the chest. However, ultrasound does not provide much predicting value in the outcome of the labor. [7]

Anatomy and Physiology

Before discussing the mechanism of labor in the face or brow presentation, it is crucial to highlight some anatomical landmarks and their measurements.

Planes and Diameters of the Pelvis

The three most important planes in the female pelvis are the pelvic inlet, mid pelvis, and pelvic outlet.

Four diameters can describe the pelvic inlet: anteroposterior, transverse, and two obliques. Furthermore, based on the different landmarks on the pelvic inlet, there are three different anteroposterior diameters, named conjugates: true conjugate, obstetrical conjugate, and diagonal conjugate. Only the latter can be measured directly during the obstetric examination. The shortest of these three diameters is obstetrical conjugate, which measures approximately 10.5 cm and is a distance between the sacral promontory and 1 cm below the upper border of the symphysis pubis. This measurement is clinically significant as the fetal head must pass through this diameter during the engagement phase. The transverse diameter measures about 13.5cm and is the widest distance between the innominate line on both sides.

The shortest distance in the mid pelvis is the interspinous diameter and usually is only about 10 cm.

Fetal Skull Diameters

There are six distinguished longitudinal fetal skull diameters:

Suboccipito-bregmatic: from the center of anterior fontanelle (bregma) to the occipital protuberance, measuring 9.5 cm. This is the presenting diameter in vertex presentation.
Suboccipito-frontal: from the anterior part of bregma to the occipital protuberance, measuring 10 cm
Occipito-frontal: from the root of the nose to the most prominent part of the occiput, measuring 11.5cm
Submento-bregmatic: from the center of the bregma to the angle of the mandible, measuring 9.5 cm. This is the presenting diameter in face presentation where the neck is hyperextended.
Submento-vertical: from the midpoint between fontanelles and the angle of the mandible, measuring 11.5cm
Occipito-mental: from the midpoint between fontanelles and the tip of the chin, measuring 13.5 cm. It is the presenting diameter in brow presentation.

Cardinal Movements of Normal Labor

Neck flexion
Internal rotation
Extension (delivers head)
External rotation (Restitution)
Expulsion (delivery of anterior and posterior shoulders)

Some of the key movements are not possible in the face or brow presentations.

Based on the information provided above, it is obvious that labor will be arrested in brow presentation unless it spontaneously changes to face or vertex, as the occipito-mental diameter of the fetal head is significantly wider than the smallest diameter of the female pelvis. Face presentation can, however, be delivered vaginally, and further mechanisms of face delivery will be explained in later sections.

Indications

As mentioned previously, spontaneous vaginal delivery can be successful in face presentation. However, the main indication for vaginal delivery in such circumstances would be a maternal choice. It is crucial to have a thorough conversation with a mother, explaining the risks and benefits of vaginal delivery with face presentation and a cesarean section. Informed consent and creating a rapport with the mother is an essential aspect of safe and successful labor.

Contraindications

Vaginal delivery of face presentation is contraindicated if the mentum is lying posteriorly or is in a transverse position. In such a scenario, the fetal brow is pressing against the maternal symphysis pubis, and the short fetal neck, which is already maximally extended, cannot span the surface of the maternal sacrum. In this position, the diameter of the head is larger than the maternal pelvis, and it cannot descend through the birth canal. Therefore the cesarean section is recommended as the safest mode of delivery for mentum posterior face presentations.

Attempts to manually convert face presentation to vertex, manual or forceps rotation of the persistent posterior chin to anterior are contraindicated as they can be dangerous.

Persistent brow presentation itself is a contraindication for vaginal delivery unless the fetus is significantly small or the maternal pelvis is large.

Continuous electronic fetal heart rate monitoring is recommended for face and brow presentations, as heart rate abnormalities are common in these scenarios. One study found that only 14% of the cases with face presentation had no abnormal traces on the cardiotocograph. [8] It is advised to use external transducer devices to prevent damage to the eyes. When internal monitoring is inevitable, it is suggested to place monitoring devices on bony parts carefully.

People who are usually involved in the delivery of face/ brow presentation are:

Experienced midwife, preferably looking after laboring woman 1:1
Senior obstetrician
Neonatal team - in case of need for resuscitation
Anesthetic team - to provide necessary pain control (e.g., epidural)
Theatre team - in case of failure to progress and an emergency cesarean section will be required.
Preparation

No specific preparation is required for face or brow presentation. However, it is essential to discuss the labor options with the mother and birthing partner and inform members of the neonatal, anesthetic, and theatre co-ordinating teams.

Technique or Treatment

Mechanism of Labor in Face Presentation

During contractions, the pressure exerted by the fundus of the uterus on the fetus and pressure of amniotic fluid initiate descent. During this descent, the fetal neck extends instead of flexing. The internal rotation determines the outcome of delivery, if the fetal chin rotates posteriorly, vaginal delivery would not be possible, and cesarean section is permitted. The approach towards mentum-posterior delivery should be individualized, as the cases are rare. Expectant management is acceptable in multiparous women with small fetuses, as a spontaneous mentum-anterior rotation can occur. However, there should be a low threshold for cesarean section in primigravida women or women with large fetuses.

When the fetal chin is rotated towards maternal symphysis pubis as described as mentum-anterior; in these cases further descend through the vaginal canal continues with approximately 73% cases deliver spontaneously. [9] Fetal mentum presses on the maternal symphysis pubis, and the head is delivered by flexion. The occiput is pointing towards the maternal back, and external rotation happens. Shoulders are delivered in the same manner as in vertex delivery.

Mechanism of Labor in Brow Presentation

As this presentation is considered unstable, it is usually converted into a face or an occiput presentation. Due to the cephalic diameter being wider than the maternal pelvis, the fetal head cannot engage; thus, brow delivery cannot take place. Unless the fetus is small or the pelvis is very wide, the prognosis for vaginal delivery is poor. With persistent brow presentation, a cesarean section is required for safe delivery.

Complications

As the cesarean section is becoming a more accessible mode of delivery in malpresentations, the incidence of maternal and fetal morbidity and mortality during face presentation has dropped significantly. [10]

However, there are still some complications associated with the nature of labor in face presentation. Due to the fetal head position, it is more challenging for the head to engage in the birth canal and descend, resulting in prolonged labor.

Prolonged labor itself can provoke foetal distress and arrhythmias. If the labor arrests or signs of fetal distress appear on CTG, the recommended next step in management is an emergency cesarean section, which in itself carries a myriad of operative and post-operative complications.

Finally, due to the nature of the fetal position and prolonged duration of labor in face presentation, neonates develop significant edema of the skull and face. Swelling of the fetal airway may also be present, resulting in respiratory distress after birth and possible intubation.

Clinical Significance

During vertex presentation, the fetal head flexes, bringing the chin to the chest, forming the smallest possible fetal head diameter, measuring approximately 9.5cm. With face and brow presentation, the neck hyperextends, resulting in greater cephalic diameters. As a result, the fetal head will engage later, and labor will progress more slowly. Failure to progress in labor is also more common in both presentations compared to vertex presentation.

Furthermore, when the fetal chin is in a posterior position, this prevents further flexion of the fetal neck, as browns are pressing on the symphysis pubis. As a result, descend through the birth canal is impossible. Such presentation is considered undeliverable vaginally and requires an emergency cesarean section.

Manual attempts to change face presentation to vertex, manual or forceps rotation to mentum anterior are considered dangerous and are discouraged.

Enhancing Healthcare Team Outcomes

A multidisciplinary team of healthcare experts supports the woman and her child during labor and the perinatal period. For a face or brow presentation to be appropriately diagnosed, an experienced midwife and obstetrician must be involved in the vaginal examination and labor monitoring. As fetal anomalies, such as anencephaly or goiter, can contribute to face presentation, sonographers experienced in antenatal scanning should also be involved in the care. It is advised to inform the anesthetic and neonatal teams in advance of the possible need for emergency cesarean section and resuscitation of the neonate. [11] [12]

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Disclosure: Julija Makajeva declares no relevant financial relationships with ineligible companies.

Disclosure: Mohsina Ashraf declares no relevant financial relationships with ineligible companies.

This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits others to distribute the work, provided that the article is not altered or used commercially. You are not required to obtain permission to distribute this article, provided that you credit the author and journal.

Cite this Page Makajeva J, Ashraf M. Delivery, Face and Brow Presentation. [Updated 2023 Jan 9]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

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Fetal Position in the Womb

Risks and Complications
Altering Fetal Position

Most fetuses are nestled inside the uterus (womb), curled up tight. This cozy position, knees to chest, is known as the fetal position. During pregnancy, the fetal position also refers to the direction a fetus faces in the uterus and is especially important as you approach delivery.

This article reviews the fetal position and how you and your providers change the fetal position before delivery when necessary.

Illustration by Zoe Hansen for Verywell Health

Fetal Position (or Presentation) In Utero

The ideal fetal position for birth is head down, spine parallel to the pregnant person's spine, face toward the back of the pregnant person's body with the chin tucked and arms folded across the chest. However, there are variations to the fetal position in utero that can affect delivery.

Cephalic : The fetus is head down, with its chin tucked in and facing the pregnant person's spine.
Breech : The fetus's buttocks or feet are toward the opening of the womb.
Transverse : The fetus is sideways, at a 90-degree angle, to the pregnant person's spine.

Healthcare providers describe the fetal position in the uterus in terms of the fetal lie, position, and presentation.

Fetal lie refers to how the fetus's spine aligns with the gestational carrier's spine. Healthcare providers describe it as:

Longitudinal : Parallel with the pregnant person's spine
Transverse : Perpendicular to the pregnant person's spine
Oblique : At an angle to the pregnant person's spine

Fetal Position

"Fetal position" refers to the direction the fetus is facing. The occipital bone is at the back of the fetus's head. Healthcare providers use this bone as a point of reference when describing fetal position, as follows: It is described as:

Occiput anterior : The occipital bone is at the front of the birthing person's body, so the fetus is facing backward.
Occiput posterior : The occipital bone is at the back of the birthing person's body, so the fetus is facing forward.

Fetal Presentation

Fetal presentation indicates the body part closest to the birth canal, also called the presenting part. The ideal presentation is the cephalic or vertex position. This when the fetus's head is down and the chin is tucked in and facing the spine. However, in some cases, the fetus can present with one of the following body parts closest to the birth canal:

Buttocks (also known as the breech position)
Face or brow

Positions and Risk of Delivery Complications

Fetuses move, kick, and roll throughout pregnancy. However, during the third trimester, as space in the uterus gets tight, most fetuses naturally reposition into the cephalic fetal position, which is ideal for delivery.

However, some settle into breech or transverse positions. You can still deliver the baby in the following positions, but it can prolong labor and increase the risk of the following complications, which can restrict the baby’s oxygen supply:

Shoulder dystocia : Occurs when the fetus's shoulder gets stuck in your pelvis
Head entrapment : Occurs when the fetus's head is stuck inside a partially dilated cervix
Umbilical cord compression or prolapse : Occurs when the umbilical cord is compressed and restricts oxygen and blood flow to the baby

How to Alter Fetal Position Before Delivery

When a healthcare provider performs an ultrasound and vaginal exam near the end of pregnancy , they may find that the fetus isn't in the ideal head-down position. They can help you explore options to alter the fetal position before delivery.

At home, you can try playing music by placing headphones or a speaker at the bottom of your uterus to encourage the fetus to turn. You can also put something cool on the top of your stomach and something warm (not hot) at the bottom to promote movement.

Specific exercises and yoga poses can help relax your pelvis and uterus, creating more room for the fetus and nudging it into the head-down position. Talk with your healthcare provider before attempting these techniques:

Cat-cow stretch : Get on your hands and knees and alternate between arching your back upward (like a cat) and dipping it downward (like a cow).
Pelvic circles : Gently make circles with your pelvis while standing.
Child’s pose : Kneel on the ground, sit back on your heels, and stretch your arms forward, lowering your chest towards the ground. You can rest your forehead on the floor or on a cushion. Rest in this pose for 10-15 minutes.
Pelvic tilts : Lie on your back with your knees bent and your feet flat on the floor. Slowly tilt your hips upward, then release, returning to a neutral position. You can do this exercise for 10 to 20 minutes three times daily.

Alternative options include seeing a chiropractor or acupuncturist that your healthcare provider recommends. Chiropractors align your hips and spine. Acupuncture is an Eastern medicine practice that involves inserting tiny needles in certain areas to balance your body’s energy.

At the Hospital

At the hospital, your provider may try an external cephalic version (ECV), in which they apply pressure to your belly to turn the fetus's head down.

Providers typically perform ECVs around 37 to 39 weeks' gestation, when the fetal size and the amount of amniotic fluid are ideal. An ECV is generally safe, but there are some risks, including fetal distress and preterm labor (rare).

The success rate of an ECV is about 60%. If an ECV is unsuccessful, your provider may recommend a surgical delivery known as a cesarean section (C-section). Before this surgical procedure, you will receive spinal anesthesia (numbing medicine), and your provider will make incisions in your belly to deliver the baby.

The fetal position indicates fetal alignment and presentation in the uterus. The cephalic (head-down) position is ideal for delivery. While it is possible to vaginally deliver a baby in other fetal positions, the risk of complications increases. There are ways to try to move the fetus at home or in the hospital; however, discuss these options with a healthcare provider before trying them at home.

Merck Manuals Consumer Version. Fetal presentation, position, and lie (including breech presentation) .

Yang L, Yi T, Zhou M, Wang C, Xu X, Li Y, Sun Q, Lin X, Li J, Meng Z. Clinical effectiveness of position management and manual rotation of the fetal position with a U-shaped birth stool for vaginal delivery of a fetus in a persistent occiput posterior position . J Int Med Res . 2020;48(6):300060520924275. doi:10.1177/0300060520924275

American Academy of Family Physicians. What can I do if my baby is breech ?

Felemban AS, Arab K, Algarawi A, Abdulghaffar SK, Aljahdali KM, Alotaifi MA, Bafail SA, Bakhudayd TM. Assessment of the successful external cephalic version prognostic parameters effect on final mode of delivery . Cureus. 2021;13(7):e16637. doi:10.7759/cureus.16637

Angolile CM, Max BL, Mushemba J, Mashauri HL. Global increased cesarean section rates and public health implications: A call to action . Health Sci Rep . 2023;6(5):e1274. doi: 10.1002/hsr2.1274

By Brandi Jones, MSN-ED RN-BC Jones is a registered nurse and freelance health writer with more than two decades of healthcare experience.

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Breech, posterior, transverse lie: What position is my baby in?

Fetal presentation, or how your baby is situated in your womb at birth, is determined by the body part that's positioned to come out first, and it can affect the way you deliver. At the time of delivery, 97 percent of babies are head-down (cephalic presentation). But there are several other possibilities, including feet or bottom first (breech) as well as sideways (transverse lie) and diagonal (oblique lie).

Fetal presentation and position

During the last trimester of your pregnancy, your provider will check your baby's presentation by feeling your belly to locate the head, bottom, and back. If it's unclear, your provider may do an ultrasound or an internal exam to feel what part of the baby is in your pelvis.

Fetal position refers to whether the baby is facing your spine (anterior position) or facing your belly (posterior position). Fetal position can change often: Your baby may be face up at the beginning of labor and face down at delivery.

Here are the many possibilities for fetal presentation and position in the womb.

Medical illustrations by Jonathan Dimes

Head down, facing down (anterior position)

A baby who is head down and facing your spine is in the anterior position. This is the most common fetal presentation and the easiest position for a vaginal delivery.

This position is also known as "occiput anterior" because the back of your baby's skull (occipital bone) is in the front (anterior) of your pelvis.

Head down, facing up (posterior position)

In the posterior position , your baby is head down and facing your belly. You may also hear it called "sunny-side up" because babies who stay in this position are born facing up. But many babies who are facing up during labor rotate to the easier face down (anterior) position before birth.

Posterior position is formally known as "occiput posterior" because the back of your baby's skull (occipital bone) is in the back (posterior) of your pelvis.

Frank breech

In the frank breech presentation, both the baby's legs are extended so that the feet are up near the face. This is the most common type of breech presentation. Breech babies are difficult to deliver vaginally, so most arrive by c-section .

Some providers will attempt to turn your baby manually to the head down position by applying pressure to your belly. This is called an external cephalic version , and it has a 58 percent success rate for turning breech babies. For more information, see our article on breech birth .

Complete breech

A complete breech is when your baby is bottom down with hips and knees bent in a tuck or cross-legged position. If your baby is in a complete breech, you may feel kicking in your lower abdomen.

Incomplete breech

In an incomplete breech, one of the baby's knees is bent so that the foot is tucked next to the bottom with the other leg extended, positioning that foot closer to the face.

Single footling breech

In the single footling breech presentation, one of the baby's feet is pointed toward your cervix.

Double footling breech

In the double footling breech presentation, both of the baby's feet are pointed toward your cervix.

Transverse lie

In a transverse lie, the baby is lying horizontally in your uterus and may be facing up toward your head or down toward your feet. Babies settle this way less than 1 percent of the time, but it happens more commonly if you're carrying multiples or deliver before your due date.

If your baby stays in a transverse lie until the end of your pregnancy, it can be dangerous for delivery. Your provider will likely schedule a c-section or attempt an external cephalic version , which is highly successful for turning babies in this position.

Oblique lie

In rare cases, your baby may lie diagonally in your uterus, with his rump facing the side of your body at an angle.

Like the transverse lie, this position is more common earlier in pregnancy, and it's likely your provider will intervene if your baby is still in the oblique lie at the end of your third trimester.

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BabyCenter's editorial team is committed to providing the most helpful and trustworthy pregnancy and parenting information in the world. When creating and updating content, we rely on credible sources: respected health organizations, professional groups of doctors and other experts, and published studies in peer-reviewed journals. We believe you should always know the source of the information you're seeing. Learn more about our editorial and medical review policies .

Ahmad A et al. 2014. Association of fetal position at onset of labor and mode of delivery: A prospective cohort study. Ultrasound in obstetrics & gynecology 43(2):176-182. https://www.ncbi.nlm.nih.gov/pubmed/23929533 Opens a new window [Accessed September 2021]

Gray CJ and Shanahan MM. 2019. Breech presentation. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK448063/ Opens a new window [Accessed September 2021]

Hankins GD. 1990. Transverse lie. American Journal of Perinatology 7(1):66-70. https://www.ncbi.nlm.nih.gov/pubmed/2131781 Opens a new window [Accessed September 2021]

Medline Plus. 2020. Your baby in the birth canal. U.S. National Library of Medicine. https://medlineplus.gov/ency/article/002060.htm Opens a new window [Accessed September 2021]

Where to go next

Fetal Presentation, Position, and Lie (Including Breech Presentation)

Key Points |

Abnormal fetal lie or presentation may occur due to fetal size, fetal anomalies, uterine structural abnormalities, multiple gestation, or other factors. Diagnosis is by examination or ultrasonography. Management is with physical maneuvers to reposition the fetus, operative vaginal delivery , or cesarean delivery .

Terms that describe the fetus in relation to the uterus, cervix, and maternal pelvis are

Fetal presentation: Fetal part that overlies the maternal pelvic inlet; vertex (cephalic), face, brow, breech, shoulder, funic (umbilical cord), or compound (more than one part, eg, shoulder and hand)

Fetal position: Relation of the presenting part to an anatomic axis; for vertex presentation, occiput anterior, occiput posterior, occiput transverse

Fetal lie: Relation of the fetus to the long axis of the uterus; longitudinal, oblique, or transverse

Normal fetal lie is longitudinal, normal presentation is vertex, and occiput anterior is the most common position.

Abnormal fetal lie, presentation, or position may occur with

Fetopelvic disproportion (fetus too large for the pelvic inlet)

Fetal congenital anomalies

Uterine structural abnormalities (eg, fibroids, synechiae)

Multiple gestation

Several common types of abnormal lie or presentation are discussed here.

Transverse lie

Fetal position is transverse, with the fetal long axis oblique or perpendicular rather than parallel to the maternal long axis. Transverse lie is often accompanied by shoulder presentation, which requires cesarean delivery.

Breech presentation

There are several types of breech presentation.

Frank breech: The fetal hips are flexed, and the knees extended (pike position).

Complete breech: The fetus seems to be sitting with hips and knees flexed.

Single or double footling presentation: One or both legs are completely extended and present before the buttocks.

Types of breech presentations

Breech presentation makes delivery difficult ,primarily because the presenting part is a poor dilating wedge. Having a poor dilating wedge can lead to incomplete cervical dilation, because the presenting part is narrower than the head that follows. The head, which is the part with the largest diameter, can then be trapped during delivery.

Additionally, the trapped fetal head can compress the umbilical cord if the fetal umbilicus is visible at the introitus, particularly in primiparas whose pelvic tissues have not been dilated by previous deliveries. Umbilical cord compression may cause fetal hypoxemia.

Predisposing factors for breech presentation include

Preterm labor

Uterine abnormalities

Fetal anomalies

If delivery is vaginal, breech presentation may increase risk of

Umbilical cord prolapse

Birth trauma

Perinatal death

Face or brow presentation

In face presentation, the head is hyperextended, and position is designated by the position of the chin (mentum). When the chin is posterior, the head is less likely to rotate and less likely to deliver vaginally, necessitating cesarean delivery.

Brow presentation usually converts spontaneously to vertex or face presentation.

Occiput posterior position

The most common abnormal position is occiput posterior.

The fetal neck is usually somewhat deflexed; thus, a larger diameter of the head must pass through the pelvis.

Progress may arrest in the second phase of labor. Operative vaginal delivery or cesarean delivery is often required.

Position and Presentation of the Fetus

Toward the end of pregnancy, the fetus moves into position for delivery. Normally, the presentation is vertex (head first), and the position is occiput anterior (facing toward the pregnant patient's spine) with the face and body angled to one side and the neck flexed.

Abnormal presentations include face, brow, breech, and shoulder. Occiput posterior position (facing toward the pregnant patient's pubic bone) is less common than occiput anterior position.

If a fetus is in the occiput posterior position, operative vaginal delivery or cesarean delivery is often required.

In breech presentation, the presenting part is a poor dilating wedge, which can cause the head to be trapped during delivery, often compressing the umbilical cord.

For breech presentation, usually do cesarean delivery at 39 weeks or during labor, but external cephalic version is sometimes successful before labor, usually at 37 or 38 weeks.

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Transcripts

Vertex Pharmaceuticals, Inc. (VRTX) Q2 2024 Earnings Call Transcript

Vertex Pharmaceuticals, Inc. ( NASDAQ: VRTX ) Q2 2024 Earnings Conference Call August 1, 2024 4:30 PM ET

Company Participants

Reshma Kewalramani - Chief Executive Officer, President Stuart Arbuckle - Chief Operating Officer Charlie Wagner - Chief Financial Officer. Susie Lisa - Senior Vice President, Investor Relations

Conference Call Participants

Salveen Richter - Goldman Sachs David Risinger - Leerink Partners Jessica Fye - J.P. Morgan Evan Seigerman - BMO Capital Markets Chris Raymond - Piper Sandler Terence Flynn - Morgan Stanley Mohit Bansal - Wells Fargo Liisa Bayko - Evercore ISI Michael Yee - Jeffries

Good day! And welcome to the Vertex Pharmaceuticals Second Quarter 2024 Earnings Conference Call. All participants will be in a listen only mode. [Operator Instructions]. After today's presentation, there will be an opportunity to ask questions. Please note this event is being recorded.

I would now like to turn the conference over to Ms. Susie Lisa. Please go ahead.

Good evening all. My name is Susie Lisa, and as the Senior Vice President of Investor Relations, it is my pleasure to welcome you to our second quarter 2024 financial results conference call.

On tonight's call, making prepared remarks, we have Dr. Reshma Kewalramani, Vertex's CEO and President; Stuart Arbuckle, Chief Operating Officer; and Charlie Wagner, Chief Financial Officer. We recommend that you access the webcast slides as you listen to this call. The call is being recorded, and a replay will be available on our website.

We will be make forward-looking statements on this call that are subject to the risks and uncertainties discussed in detail in today's press release and in our filings with the Securities and Exchange Commission. These statements, including, without limitation, those regarding Vertex's marketed medicines for cystic fibrosis, sickle cell disease and beta-thalassemia, our pipeline including the potential near-term launches of the Vanzacaftor Triple in CF and Suzetrigine in moderate to severe acute pain, and Vertex's future financial performance are based on management's current assumptions.

Actual outcomes and events could differ materially. I would also note that the select financial results and guidance that we will review on the call this evening are presented on a non-GAAP basis.

I will now turn the call over to Reshma.

Reshma Kewalramani

Thanks, Susie. Good evening all. And thank you for joining us on the call today. We've continued our momentum from Q1 with another quarter of excellent performance across the board, including outstanding commercial execution in both CF and the early launch of CASGEVI.

Our preparedness for the potential near-term launches of the Vanzacaftor Triple in CF and Suzetrigine in acute pain, as well as the rapid advancement of our broad and deep pipeline.

In CF, we continue to reach more patients delivering $2.65 billion in revenue in Q2, and based on this result and our outlook, we are increasing our full-year product revenue guidance to $10.65 billion to $10.85 billion, which at the midpoint represents 9% growth versus 2023.

In sickle cell disease and beta thalassemia, we are pleased with the reception from patients, physicians, and payers as we continue the ongoing launch of CASGEVI to bring this potentially transformative medicine to patients across multiple regions, and we are very excited about the multiple near-term opportunities to reach more patients and deliver additional revenue growth from our programs that have completed pivotal development, including the completion and acceptance of two significant regulatory submissions.

The Vanzacaftor Triple in patients with cystic fibrosis, six years and older, which has been given priority review designation, and VX-548 or Suzetrigine in moderate to severe acute pain, which has also been granted priority review by the FDA.

Lastly, on the mid and late stage pipeline, I am very pleased with our continued rapid progress. I'll call out three specific programs. First, the Suzetrigine LSR Phase 2 Study has significantly accelerated, and we now expect Phase 2 results by the end of this year.

Second, in the VX-880 Phase 1/2 trial in Type 1 Diabetes, we have completed enrollment and dosing in the original 17-patient study, and we have secured regulatory endorsement to expand the study to 37 patients in total as we advance towards pivotal development. And third, in the Povetacicept program, having completed successful end of Phase 2 regulatory meetings, we will initiate the Phase 3 pivotal trial in IgA nephropathy later this month.

With those highlights, let me now turn to an R&D review limiting my comments this quarter to the programs with the most significant recent updates, cystic fibrosis, pain, type 1 diabetes, and IgA nephropathy.

Starting with CF, we are very pleased with the Phase 3 results from the Vanzacaftor Triple program we announced in early February, as we continued to drive towards our ultimate goal of bringing all eligible patients to carrier levels, indeed to normal levels of CFTR function as measured by sweat chloride.

The Vanzacaftor Triple demonstrated an even greater reduction in sweat chloride than TRIKAFTA, a very high bar to have crested, and thus sets the stage for the potential to have a new standard in the treatment of CF.

The Vanzacaftor Triple also offers the convenience of one-daily dosing and a substantially lower royalty burden. With regard to the vanza global regulatory submissions, in addition to the US acceptance our filings have also been validated by the EMA in the EU, and the MHRA in the UK.

With regard to VX-522 our CFTR mRNA therapy in development with our partners at Moderna, it has completed the single ascending dose portion of the Phase 1/2 study and continues in the multiple ascending dose portion.

As a reminder, VX-522 seeks to provide treatment for the more than 5,000 people with CF who do not make any CFTR protein and therefore cannot benefit from CFTR modulators. Based on the pace of enrollment and study dynamics, our current expectation is to complete the study and share both efficacy and safety results from the study in the first half of 2025.

Moving now to the pain program and our portfolio of novel, highly selective Nav1.8 and Nav1.7 pain signal inhibitors. In acute pain, a few points to highlight. First, we are very pleased that the Suzetrigine submission has been accepted and granted priority review by the FDA with a PDUFA target action date of January 30th, 2025.

Second, our next in class Nav1.8 pain signal inhibitor, VX-993, is in the clinic in a Phase 1 trial with the IV formulation and is currently enrolling and dosing healthy volunteers. Third, VX-993 will soon enter a Phase 2 study with the oral formulation in acute pain following bunionectomy surgery. This study is on track to begin later this quarter. And lastly, we continue to make strong progress preclinically with our Nav1.7 pain signal inhibitor program that may be used alone or in combination with Nav1.8 inhibitors.

Just as in acute pain, we have multiple programs moving rapidly through development in Peripheral Neuropathic Pain or PNP. Starting with Painful Lumbosacral Radiculopathy or LSR, a condition that impacts more than 4 million Americans. There is a high unmet need in LSR. In the US, there are no medicines approved specifically for the treatment of pain from LSR.

As mentioned in my opening remarks, the pace of enrollment in this study has been rapid and significantly exceeded our projections. Study enrollment is now complete and we anticipate sharing Phase 2 LSR results by the end of this year.

Also in Peripheral Neuropathic Pain, we are excited to begin the Phase 3 pivotal program for Suzetrigine in painful diabetic peripheral neuropathy or DPN later this quarter. The DPN pivotal program consists of two identical randomized control trials of approximately 1100 patients each, with Suzetrigine at a dose of 70 milligrams, one daily, and evaluating the change from baseline to week 12 in NPRS pain scores relative to placebo.

The RCTs also include an active comparator arm of Pregabalin. A key secondary endpoint is changed from baseline at week 12 in NPRS score for Suzetrigine versus Pregabalin assessed for non-inferiority. And if we meet non-inferiority, then we will test for superiority versus Pregabalin.

Lastly in PNP, I am pleased to share that we will soon initiate a Phase 2 study with the oral formulation of VX-993 in diabetic peripheral neuropathy, designed similarly to the Suzetrigine Phase 2 DPN study, this trial is also on track to begin this quarter.

Turning now to Type 1 Diabetes, VX-880s are stem cell derived, fully differentiated islet cell therapy for people with T1D and impaired hypoglycemic awareness, who experience severe hypoglycemic events despite optimal medical care.

At the ADA meeting in June, an oral presentation from the ongoing Phase 1/2 Study included updated data with more patients and longer duration of follow-up, and continued to demonstrate the potential of VX-880 as a functional cure for patients with T1D.

The data reflected 12 patients from Parts B and C of the study who received a full dose of VX-880 as a single infusion and had at least 3 months of follow-up. The results are remarkable. Specifically, all patients demonstrated islet cell engraftment and glucose-responsive insulin production by day 90.

All 12 patients achieved hemoglobin A1c levels less than 7%, and all 12 patients also had a time and range for glucose levels of 70% or greater. 11 of the 12 patients greatly reduced or completely eliminated exogenous insulin use and the three patients with 12 months of follow-up and therefore evaluable for the primary endpoint each met the primary endpoint of elimination of severe hypoglycemic events with a hemoglobin A1c level below 7% as well as the secondary endpoint of insulin independence.

With these results we are planning forward towards the next phase of development for VX-880. To that end we are very pleased to have secured regulatory approval to expand the original 17 patient study which is fully enrolled and dosed to include an additional 20 participants. We look forward to continuing the work with regulators to finalize the requirements for pivotal development and updating you on those discussions.

Beyond VX-880 our cells + device or VX-264 program encapsulates the same VX-880 cells in a proprietary device designed to eliminate the need for immunosuppressants. VX-264 is in a Phase 1/2 multi-part global study. We have completed Part A of the study at an initial dose with a stagger between patients. We are currently enrolling and dosing patients in Part B which is at the full target dose also with a stagger between patients. As a reminder Part C of the trial is at the full target dose with no stagger between patients.

The last major R&D update pertains to povetacicept the lead asset from our recently closed acquisition of Alpine Immune Sciences where enthusiasm for both the acquisition and pove remains high. As a reminder pove holds the promise of being a pipeline and a product and has best-in-class potential for the lead indication in IgA nephropathy given its mechanism of action with dual inhibition of both APRIL and BAFF, its pre-clinical profile and the clinical data through Phase 2 in proteinuria, hematuria and GFR.

These attributes plus pove's once monthly dose frequency and small volume subcutaneous route of administration give us high confidence in its potential to be a transformative medicine for patients with IgAN. I am pleased to share that we are on track to initiate the global Phase 3 RAINIER study of povetacicept in patients with IgA nephropathy this month.

To recap we had successful end of Phase 2 meetings with the FDA and global regulatory authorities and we're very pleased to have reached agreement on the following important elements.

The pivotal program is designed as a single global randomized double-blind placebo controlled trial of approximately 480 patients with biopsy proven IgA and proteinuria. Patients will be randomized to receive either pove or placebo on top of standard of care.

In the U.S. the Phase 3 design affords us the opportunity to submit for an accelerated approval. A pre-planned interim analysis will take place when a certain number of patients reaches 36 weeks of treatment to evaluate the change in proteinuria from baseline to week 36. For full approval the study will continue through week 104 and an assessment of GFR.

Beyond the Phase 3 study in IgA nephropathy pove is also being evaluated in two Phase 2 basket trials one in renal diseases termed RUBY3 and a second in B cell mediated cytopenias termed Ruby4. We look forward to readouts from some cohorts in these studies later this year and into next.

To close the pipeline review, a brief update on VX-634 and VX-668 in Alpha-1 Antitrypsin Deficiency or AATD. Safety was demonstrated in the Phase 1 studies of both VX-634 and 668. However based on the Phase 1 biomarker analyses we have determined that neither VX-634 nor VX-668 would deliver transformative efficacy for people with AATD and therefore we have decided to discontinue development of both molecules. With these learnings our research efforts in AATD will continue.

I'll now turn it over to Stuart for a commercial update.

Stuart Arbuckle

Thanks Reshma. I'll first discuss CF then provide some highlights of the ongoing CASGEVY launch and the outlook for Suzetrigine in acute pain. As Reshma noted we once again delivered strong results in CF as we grew the number of eligible patients taking our CFTR modulators and we continue to expect sustained growth in CF over the near, medium and long term.

In the near term we continue to focus on reaching more eligible patients including younger age groups as with the ongoing KAFTRIO launches in the two to five age group in Europe. With anticipated global approvals for additional rare mutations later this year and through additional geographies such as Brazil where we now have national reimbursement for TRIKAFTA for patients’ ages six and above.

We were also pleased to have announced in June an extended long-term reimbursement agreement with NHS England which ensures access to our CFTR modulators for all existing and future eligible CF patients in England. Comparable arrangements have subsequently been entered into in Scotland, Wales and Northern Ireland. The agreements are a result of positive recommendations for NICE and SMC for our CFTR modulators.

In the medium term we anticipate growth will be driven by the launch of our fifth CFTR modulator therapy the Vanzacaftor Triple combination. We believe many existing TRIKAFTA patients may seek to achieve even greater levels of CFTR function and the added convenience of once daily dosing, and there are also more than 6,000 patients who have discontinued one of our current CFTR modulators who also may be interested in a new treatment option.

We continue to execute our vanz pre-launch activities including pre-approval information exchange with payers and are encouraged by the outlook. Longer term we expect continued growth in CF from developing medicines for the more than 5,000 people with CF who do not respond to CFTR modulators which is the focus of our mRNA program VX-522.

Now turning to CASGEVY and our launches in sickle cell disease and beta thalassemia. We continue to make strong progress with ATC activation as well as physician, patient and payer engagement, as we work to bring this potentially curative therapy to patients around the globe.

CASGEVY represents an enormous advancement for the estimated 35,000 people living with severe sickle cell disease and transfusion dependent beta thalassemia in the US and Europe as well as the estimated 23,000 eligible patients in the Kingdom of Saudi Arabia and Bahrain.

To update you on the two key metrics we are sharing externally as important markers of our early launch progress. Firstly ATC activation, we're pleased with our progress as we now have more than 35 activated centers up from 25 last quarter and 9 at launch. We continue to expect to activate approximately 75 total ATCs globally.

Secondly, patient cell collections. We continue to see a growing number of patients beginning the treatment journey. Approximately 20 patients have already had cells collected. As mentioned last quarter patients are initiating the treatment journey in every region where CASGEVY is approved, the US, Europe and the Middle East. And we are pleased to report growth in patient cell collections across all of these regions this quarter.

We also continue to make strong progress with payers in all regions who recognize the transformative clinical benefits of CASGEVY and are moving quickly to provide rapid and equitable access. Outside the US we are building upon our early successes such as the early access program in France for TDT, and we now have an early access program approved there for sickle cell disease as well as reimbursement in Austria, Bahrain and KSA.

In the US given payers support across all market segments commercial, Medicaid and Medicare, I'm pleased to report that we do not see coverage as a significant obstacle to patient access. We have always known that CASGEVY offers an enormous advancement for patients. We've also consistently communicated that the patient journey that is the process to go from patient interest all the way to infusion of edited cells is long and complex.

Whilst it's still early in the launch we have gained many learnings, interest level is high among patients, physicians, governments and other stakeholders. The value of CASGEVY has been widely recognized leading to broad access and reimbursement by payers. The patient opportunity in the Middle East is particularly significant given the high prevalence of these Hemoglobinopathies and government's clear focus on elevating the health of their citizens.

And lastly the treatment process does take time, but we are now even more confident in our view that CASGEVY will help large numbers of patients around the world and represents a multi-billion dollar opportunity.

Shifting now to Suzetrigine, we believe this novel, highly selective Nav1.8 pain signal inhibitor has the potential to provide a transformative treatment option for the 90 million patients suffering from acute and peripheral neuropathic pain in the US. This quarter, I'll limit my commercial comments to the opportunity in acute pain.

We have continued to make significant progress building out our commercial team. We've now completed hiring of our strategic account leads who will primarily focus on the leadership and formulary decision makers at IDNs, as well as our pain territory account managers, who post approval will call on hospitals and other large treatment sites, such as ambulatory surgical centers.

Recall that approximately 80 million patients are prescribed a medicine for moderate to severe acute pain each year in the US, with approximately two thirds of patients treated in the institutional setting. As a result, our field force will primarily focus on this institutional setting.

We have begun engaging in pre-approval information exchanges in those institutional settings with IDN leadership and formulary decision makers who have responsibility for formularies that enable use in both the inpatient and discharge settings.

We've encountered high levels of enthusiasm for a new class of treatment for pain, specifically for an effective and well-tolerated pain medication that does not possess addictive properties by way of its mechanism of action.

Hospital formulary and payer processes are well-defined, and we are engaging appropriately to encourage and support swift reviews by the relevant bodies like P&T Committees, including by providing key clinical and economic information.

Depending on the institution or organization, it can take up to 12 months post-approval for hospital formulary and payer decisions to be finalized, but we are working to accelerate these timelines. We anticipate engaging in contracting discussions in the latter half of 2024 with the goal of building formulary and payer coverage during 2025.

We also continue to be engaged with federal and state policy makers, including state governors who have expressed strong interest in a novel, highly effective and well-tolerated treatment for pain without the addictive potential of opioids.

Federally, in December 2022, Congress passed the No Pain Act in which non-opioid therapies are eligible for separate payment for Medicare patients in the outpatient and ACS settings, beginning in January 2025. It is promising to see CMS continuing the process of implementation as the Annual Outpatient Prospective Payment System, or OPPS, proposed rule was released for public comment last month.

Because Suzetrigine is still investigational, it is not currently included in the list of seven drugs in the proposed rule, but we fully expect Suzetrigine will be eligible for separate payment once it is FDA approved.

We view the No Pain Act as an important indication of the broad range of supportive policy initiatives, both at the federal and state level that can provide a meaningful tailwind to Suzetrigine adoption. We are also encouraged by the progress of the Alternatives to Pain Act, which aims to level the playing field for access to non-opioids for Medicare Part D patients.

In the discharge or outpatient pharmacy setting, it's important to understand that patients who receive a prescription must be able to access their acute pain medication immediately. Unlike patients with asymptomatic or chronic conditions, patients in acute pain cannot wait for another day or another week to have their prescription filled.

We are therefore working with key pharmacy retail organizations to ensure broad availability of Suzetrigine nationally. In addition, we are planning a range of initiatives for the first year of launch, including co-pay assistance and other financial assistance programs to enable patients at the pharmacy to access their prescribed Suzetrigine prior to payer coverage decisions.

We are very enthusiastic about the potential launch of Suzetrigine for patients with moderate to severe acute pain and the impact we believe it will have on society. We recognize that even in the case of significant unmet need, it can take time for some components of our healthcare system to adopt new technologies, and we are working to accelerate these processes.

Ultimately, our goal is to fundamentally and forever change the way pain is treated, and we look forward to delivering on the first part of this vision for patients with moderate to severe acute pain in early 2025.

In conclusion, it's an exciting time to be at Vertex. We continue to treat more CF patients around the world and are well advanced in planning for the launch of the Vanzacaftor Triple combination. We are entering a new era of commercial diversification with the launch of CASGEVI in the US, Europe, and the Middle East. And our launch preparations for Suzetrigine in acute pain are well underway, as we seek to redefine the treatment of pain and drive further diversified revenue growth.

I will now turn the call over to Charlie to review the financials.

Charlie Wagner

Thanks Stuart. Vertex's excellent Q2 results demonstrate once again our consistent strong performance and attractive growth profile. Second quarter 2024 revenue increased 6% year-over-year to $2.65 billion with solid growth of 7% in the U.S. and 5% outside the U.S. The drivers of this strong quarter were in line with our expectations, including an anticipated reduction in channel inventories in select international markets.

Second quarter U.S. growth was driven by continued strong patient demand for TRIKAFTA. Outside the U.S., growth was also driven by strong demand, with continued uptake from the KAFTRIO launches in children's ages two to five, partially offset by the reversal of the first quarter channel inventory build.

On the expense front, Q2‘24 combined non-GAAP R&D Acquired IPR&D and SG&A expenses were $5.43 billion, compared to $1.04 billion in the second quarter of 2023. Q2’24 operating expenses include over $4.4 billion in AIPR&D charges, primarily as a result of the Alpine acquisition, which we previously disclosed as being accounted for as an asset acquisition. This compares to just $111 million of AIPR&D charges in Q2’23.

Q2’24 non-GAAP R&D expenses of $697 million were roughly flat year-over-year, reflecting ongoing investment in the advancement of our broad R&D portfolio, upset by reduced costs from the recently completed clinical trials, as well as the associated transition of certain costs from R&D to COGS and inventory.

Q2’24 non-GAAP SG&A expenses of $280 million increased 28% versus prior year, primarily as a result of investments in the commercial organization, including launch activities for CASGEVY and pre-launch activities for Suzetrigine in acute pain.

We anticipate that quarterly non-GAAP R&D and SG&A expenses will increase over the remainder of 2024 within our guidance as we advance multiple studies, including Suzetrigine, pove and inaxaplin in Phase 3 programs, VX-993 in acute and peripheral neuropathic pain studies, and the expansion of the VX-880 trial in T1D. In addition, we continue to invest in preparation for upcoming potential new launches, including the further build-out of our commercial capabilities in acute pain.

Q2’24 results reflected strong revenue and underlying operating results, though due to the $4.4 billion AIPR&D charge from Alpine transaction accounting, we reported a second quarter 2024 non-GAAP operating loss of $3.1 billion. In the second quarter of 2023, we reported $1.15 billion in non-GAAP operating income.

Our tax rate for the quarter was also impacted by the one-time, non-deductible, Alpine AIPR&D charge, leading to a reported non-GAAP tax rate for the second quarter of 2024 of negative 10%, compared to a tax rate of 21% in Q2’23. Aside from the effects of the non-deductible Alpine charge, there were no material changes in Vertex's non-GAAP tax rate for the quarter, which would have been approximately 21%.

The $4.4 billion AIPR&D charge for the Alpine acquisition equates to an impact of approximately $17 per share on Q2 GAAP and non-GAAP results, and drove a non-GAAP loss per share of $12.83 in Q2’24, compared to non-GAAP earnings per share of $3.89 in the second quarter of 2023.

We ended the quarter with $10.2 billion in cash and investments after paying approximately $5 billion to fund the acquisition of Alpine Immune Sciences. Additionally, we deployed over $300 million of cash in the second quarter to repurchase more than 700,000 shares.

Now, switching to guidance. We are raising our 2024 total product revenue guidance to a range of $10.65 billion to $10.85 billion, representing 9% revenue growth at the midpoint at current exchange rates. We continue to have high visibility into this revenue outlook, as we expect continued growth in CF as we reach more patients, including younger ones in core markets and select other countries. Guidance also continues to include a contribution in the second half of the year from the commercial launch of CASGEVI.

For Vertex operating expenses, our non-GAAP guidance continues to include a range of $4.2 billion to $4.3 billion in combined R&D and SG&A expenses, which is unchanged from the guidance provided on our last earnings call. As previously communicated, we are absorbing Alpine's projected non-GAAP operating expenses for the remainder of 2024 within our guidance range for R&D and SG&A.

For Acquired IPR&D, we now expect approximately $4.6 billion for the year, including the Alpine asset acquisition charge recorded in the second quarter. Given that the Alpine AIPR&D charge is not deductible for tax purposes, we expect a non-GAAP full year 2024 tax rate of approximately 100%. Note that the anticipated percentage tax rate is highly sensitive to projected pre-tax income. Aside from the impact of the non-deductible Alpine AIPR&D charge, our underlying full year 2024 non-GAAP effective tax rate would have remained in the range of 20% to 21%.

In closing, Vertex posted excellent results yet again as we delivered strong revenue growth, advanced our CASGEVE launch, and secured important regulatory approvals. We also strengthened our capabilities in preparation for additional near-term launches, progressed our pipeline, and made rapid progress closing and integrating Alpine, a compelling fit with Vertex's R&D strategy, with significant potential as a pipeline in a product.

We are already leveraging Vertex's clinical, regulatory, and commercial capabilities to accelerate development in IgAN, with Phase 3 set to begin this month. We are targeting U.S. accelerated approval in IgAN in late 2027 and a contribution to Vertex's revenue growth and diversification beginning in 2028.

In addition, as we move through 2024, we anticipate further important achievements, including multiple milestones in our pain portfolio, such as a Phase 2 data readout with Suzetrigine in LSR, Phase 2 initiation of VX-993 studies in acute pain and in diabetic peripheral neuropathy, as well as progress towards pivotal development in T1D.

These and other anticipated milestones of continued progress in multiple disease areas are detailed on Slide 17. We look forward to updating you on our progress on future calls.

And I'll ask Suzy to begin the Q&A period.

Question-and-Answer Session

[Operator Instructions] And your first question will come from Salveen Richter with Goldman Sachs. Please go ahead.

Salveen Richter

Good afternoon. Thanks for taking my question. Noting that around 6,000 patients have discontinued CFTR modulators, as we think about uptake for vanzacafta triple, can you help us understand what the early launch dynamics could look like and whether they could be a significant bolus of early adopters?

And then just a second question, if I may. What is the relative contribution of CASGEVI to the updated product revenue guidance? Thank you.

Hey, thanks Salveen. We won't be breaking down the revenue for the CF franchise versus CASGEVI. And I'll turn it over to Stuart, to tell you a little bit more about the vanzacafta launch dynamics.

Yes Salveen. Thanks for the question. I don't think there's going to be a single bolus of patients, based on our research with physicians that they are considering for the vanzacafta triple combination. I'd say that they are excited about the prospects for vanzacafta, both for their existing patients who are on a CFTR modulator, many of whom I think are going to be very interested in a treatment option which promises the potential for increased CFTR function, and also being the fact that it's once a day.

And then, as you say, there are also patients who are not currently on a CFTR modulator, who I think are going to welcome the opportunity for a new treatment option. So I don't think it's going to be one or the other. I think there's going to be a broad interest in the vanzacafta triple across both patients who are persistent today and those who've discontinued previously.

Next question will come from David Risinger with Leerink Partners. Please go ahead.

David Risinger

Congrats on the strong execution. I have two questions. First, could you just discuss the potential to develop VX-548 ex-U.S. for neuropathic pain? And second, could you provide the latest on your preclinical development efforts for NAV1.7 inhibitors? Thanks very much.

Sure thing. Hey Dave, this is Reshma. Let me break that into two parts and let me take the preclinical NAV1.7 first. And then, I'll turn it over to Stuart to talk about our goals ex-U.S.

So we are making really strong progress on the NAV1.7 inhibitors. They are still in preclinical development, but I would characterize it Dave, as it's in late preclinical development. And to contextualize this a little bit more for everybody else, we expect that the NAV1.7’s could be used alone in acute pain or neuropathic pain, or they could be used in combination with our NAV1.8 inhibitors, be it 548 or 993 or any in our portfolio.

With that, I'll turn it over to Stuart for a little bit on ex-U.S. ambitions.

Yeah. Hi Dave. Thanks for the question. So, I would say that the clinical landscape, and by that I mean the kind of the treatment options and the way that they are used, is very similar outside the U.S. as it is here in the U.S. with things like NSAD, acetaminophen. In neuropathic pain, things like pregabalin, gabapentin, and then obviously opioids. And that's true in both acute pain and neuropathic pain, and I know you were asking specifically about neuropathic, there are differences.

I think it's fair to say that the level of abuse and misuse of opioids is less. It's not zero, but it's less outside of the U.S. But in addition, the pricing dynamics and the value recognition of healthcare and innovation by healthcare systems outside the U.S. is very different. And as such, our focus at this time is very much on the unmet need and opportunity to serve patients here in the U.S. first, and ex-U.S. is something that we will consider later on.

The next question will come from Jessica Fye with J.P. Morgan. Please go ahead.

Jessica Fye

Hi there. Thanks for taking my question. I wanted to ask about your Type 1 diabetes effort. How do you envision the regulatory path for VX-880? And for VX-264, the encapsulated cells product, I believe you've completed Part A with the low-dose patients. Is there anything you can share with respect to kind of what you are seeing so far with that one? Thank you.

Yeah. Hi Jess. It's Reshma and let me take those two questions. Maybe we'll go with 264 first, and then we'll go to VX-880. So on VX-264, this is the Cells Plus Device Program. You're exactly right about the stage of the program. We're in Part B, which is the full dose. It's a full dose with a stagger period between patients. I would say that results are a 2025 timeframe. We're making progress, and I'm really happy to be in the clinic with both, 264 and 880.

On VX880, this is the Naked Cell Program, so cells alone. This is the one that has now completed, which is obviously a big milestone, enrollment and dosing in the original 17-patient study. We are in the phase of development where we're in full dose with patients who don't have a stagger. I'm really happy with the regulatory discussions to-date and their endorsement for us to expand the study to a total of 37 patients, so an additional 20 patients.

And with regard to your direct question on how should we think about the path forward with regard to regulatory expectations, I don't have an answer for you today, because that's exactly the conversations that we're going to complete in the coming months. But I would think about the Type 1 Diabetes Program more like a CASGEVY program than a small molecule program.

You'll remember that the CASGEVY program in either TDT or in sickle cell disease was a very efficient sample size. And what we did in the case of CASGEVY is convert it from a Phase 1-2 to a Phase 1-2-3 trial, exactly what it will look like for VX-880. I'll look forward to keeping you updated as we complete the discussions with regulators.

The next question will come from Evan Seigerman with BMO Capital Markets. Please go ahead.

Evan Seigerman

Hi, guys. Thank you so much for taking my question. I think Stuart, in your prepared remarks, you suggested that the launch of Suzetrigine might be more gradual than some other launches. Maybe once approved, can you walk me through some of the gating factors to really get this into the hands of patients to have the maximal impact on healthcare system. Kind of what you have to do once approved to really get it to these patients? Thank you.

Sure Evan. Thanks for the question. And just to be absolutely crystal clear, our enthusiasm for Suzetrigine is growing as we get closer to the launch, not diminishing. And that's due to the benefit we've got from market research and also our interactions and discussions with physicians post the Phase 3 data and the filing.

But there are practical realities that we are going to have to face. They are things like, obviously, the majority of patients with acute pain are treated in the institutional setting. That means we're going to have to go through formulary and P&T processes with those institutions.

We're going to have to work with payers and work through their formulary and other policy adoption processes. And so whilst those policies are very well defined, they do take time. And obviously, we're going to do everything we can to accelerate those timelines, and that's why we're already engaging for instance with GPOs and IDN leadership to support institutional use. We're talking with payers and PBMs to support rapid policy adoption.

In addition, we are going to want Suzetrigine to be broadly available at retail pharmacies across America, and so we're also engaging with the major retail pharmacy organizations as well.

And lastly, because we know that these processes can take time, despite the fact we're going to do everything we can to accelerate them, we are also looking at deploying a range of initiatives, including things like co-pay assistance and financial assistance programs, so that if a physician and patient decide that Suzetrigine is right for them, that patient can access the product without delay and isn't forced to kind of abandon the prescription because their particular plan or payer has not finalized their medical policy yet.

So those are some of the challenges we're going to be facing. They are not unique to Vertex. They are relatively well-defined and we're going to do everything we can to accelerate them, so that Suzetrigine can become the multi-billion dollar drug we know it's going to become.

Great, thank you.

The next question will come from Chris Raymond with Piper Sandler. Please go ahead.

Chris Raymond

Hey, thanks. Just maybe two questions. First, maybe on Pove, just a competitive question, as IgAN seems to be getting a little bit more crowded. Biogen just got access to felzartamab, which I think had pretty interesting Phase 2 data. Just maybe talk a little bit about how you view the sort of match up to that and maybe how does anti-CD38 compare to BAFF APRIL inhibition.

And then maybe a CASGEVI commercial question. Just on the HHS suit around fertility treatments for patients getting CASGEVI, can you maybe talk about the overall timelines there with that case, and maybe you also talk about how much of an impact it is to not have this reimbursement for fertility in place during the early stage of the launch. Thank you.

Sure. Hey, this is Reshma. Let me take the first question first, and then I'll turn it over to Stuart to talk about CASGEVI and how that's going.

So important things to know about IgA nephropathy. It is a rare disease, but it is one of the more common rare diseases. There's more than 130,000 with IgA nephropathy in the U.S. alone. And it's actually the most common primary glomerulonephritis. So there are lots of patients that are waiting to be served.

To-date, there is no specific therapy that treats the underlying cause of this disease. And the reason for our enthusiasm and after IgA nephropathy has been in our sandbox as it were, a disease area of interest for a long time. And after there has been some activity in this space and a full analysis by us of everything available out there, our enthusiasm for Alpine and their povetacicept, which is a dual APRIL BAFF inhibitor, comes from the fact that it is the agent that works directly on the underlying cause of the disease.

To put it in a short way, the disease is caused by B cells. It is the activation of these B cells. It is about auto antibodies. And this drug, APRIL BAFF, directly inhibits B cell proliferation, maturation and proliferation. And what we have seen by way of mechanism of action, this dual APRIL BAFF inhibition, all of the preclinical data, potency, affinity, as well as the clinical data, it is through its Phase 2 development. So we're talking about proteinuria, hematuria, GFR, and also the biomarker of what's called GDA-IgA. That's the aberrantly glycosylated IgA, which is the underlying problem, not to mention two-monthly dosing. It's subcutaneous and small volume.

You put that all together, Pove has the most transformational profile and holds the potential to be best-in-class for IgAN, but also holds the potential to have effect, transformative effect in a whole host of other B cell-mediated kidney diseases, like lupus nephritis, membranous, ANCA-associated, and a host of B cell-mediated heme diseases, like ITP, cold agglutinin disease, warm hemolytic anemia. So I couldn't be more excited about this molecule getting to its first Phase 3 program, which is IgA nephropathy. Over to you, Stuart.

Yeah, let me just take a step back before I talk specifically about fertility preservation. So, because of the treatment journey to get CASGEVI, which requires multiple trips to the activated and authorized treatment centers, and because there's only a certain number of sites in the United States, and in addition, because of the B cell-fan conditioning regimens is where the fertility risk comes in, we have sought to try and provide support to patients in two particular areas. One is travel and lodging, and the other one is in fertility preservation.

And we want to provide those support services to patients equitably, no matter what their payer is. We are able to provide both of those services to commercially insured patients, and we are able to provide travel and lodging support to government-insured patients, because that has previously been ruled on by the OIG.

What they have not given us an affirmative decision on is on fertility preservation, and that's why we have launched our suit to try and get fertility preservation approved for government-insured patients as well. It's impossible to speculate exactly on the timing of when that suit will be heard and resolved.

In the short term, I don't see it as being rate-limiting to a successful launch of CASGEVI, and I think we're already seeing that in the number of patients who are beginning the treatment journey and in the number of cell collections. Having said that, we are completely committed to the sickle cell and TET communities, and we are going to fight for their rights to get equitable access, whatever their payer.

And the next question will come from Terence Flynn with Morgan Stanley. Please go ahead.

Terence Flynn

Hi. Thanks for taking the question. Maybe two for me. Stuart, you discussed at a high level your confidence in Vanzacaftor pricing. Maybe just – I know you're not going to comment directly on the price, but just what are some of the inputs you're considering as you think about making that decision next year?

And then, any update on where we might see the full Phase 3 data for VX-548 this fall? Thank you.

Hey Terrence, let me take the second question first. I think it's now been released. The VX-548 Suzetrigine data have been accepted at the ASA Fall Conference, and it has been accepted in the Best Abstract category, so you can expect to see it there. I'm sure the teams are also going to be working on full manuscripts, probably in the fall-winter time frame, but the Congress acceptance of Suzetrigine as Best-in-Class Abstracts has already been announced. Stuart, over to you.

Yeah Terrence, on Vanzacaftor, we're going to approach the pricing of Vanzacaftor as we have with all of our medicines, which is we're going to base it on the clinical benefits and the value it provides to the patients. And as you know, we're very positive about the Vanzacaftor profile. It performed brilliantly in the Phase 3 program, non-inferior as anticipated to TRIKAFTA on FEV1, but demonstrated superior restoration of CFTR function as measured by sweat chloride, and of course, it has the convenience of being once daily. So we're going to take all of those factors into consideration when thinking of the pricing, which is obviously a decision we'll make much closer to the launch.

The next question will come from Mohit Bansal with Wells Fargo. Please go ahead.

Mohit Bansal

Great. Thank you very much for taking my question. Maybe one question on LS-SAR trial. If you could help set some expectations there, it's a placebo-controlled trial, so did we think a two-point improvement just like a DPN trial would be good enough here? And then the other one is that, are you expecting any adcomm for the pain, acute pain program at this point? Thank you.

Sure. Mohit, let me take the second question first. As I said in my prepared remarks, we are thrilled that Suzetrigine, the submission was not only accepted, but granted priority review. The agency has let us know that they do not plan to hold an adcomm as it stands today, but also as you know, the agency can let us know that they wish to have one at any time between the acceptance of the filing and the actual approval.

On the LS-SAR, so that's also a VX-548 trial. That's the trial that has significantly, honestly, far significantly exceeded our projections in terms of enrollment and study completion. We're now expecting that study to finish this year and for us to be able to share results this year. So with regard to this study and how you can think about it, it uses the high dose, so the 69 milligrams from the Phase 2 study of DPN.

The big difference between DPN and LS-SAR, is that LS-SAR has no specific therapy approved for the treatment of this kind of radiculopathy pain. And so our Phase 2 trial in LS-SAR is a within group, so it's within arm change of the NPRS score for the LS-SAR – sorry, for the VX-548 group. And equally we'll have the placebo group within group change.

And the goal for the LS-SAR study, which frankly was the same goal as the DPN study, is to get a magnitude of the treatment effect, so that we can appropriately power the Phase 3 study. And the reason the DPN study had a pregabalin arm, was because pregabalin is an available therapy for the treatment of DPN. This study, LS-SAR, has a placebo arm because there is no specifically approved therapy for the treatment of LS-SAR. I hope that helps.

Chuck, we'll take two more questions, please.

Yes, ma'am. The next question will come from Liisa Bayko with Evercore ISI. Please go ahead.

Liisa Bayko

Hi, thanks for taking the question. Just to follow up on Vanzacaftor, maybe you can talk about how you are expecting the rollout there in terms of patient uptake. It's not quite as much of a leap as some of your other therapies are, but nevertheless, like the value there is obvious. Do you expect like a quite quick conversion? Will it happen slowly over time? Do you think the vast majority of patients will switch over? Just curious about what the feedback's been there. Thanks.

Stuart, any additional comments to make?

A - Stuart Arbuckle

Yeah, just that we are as excited about the Vanzacaftor launch as any of our other CFTR modulators for the reasons I think you were referring to Liisa. It's got a great benefit-risk profile, and I think it is going to as I said earlier, I think it's going to be equally of interest to patients who are on a CFTR modulator today, but would like increased CFTR function as demonstrated by sweat chloride, because these patients know that that is important for their kind of health and well-being. But I think it's also going to be of value to those who've discontinued.

So as I said earlier on, I really don't think there's going to be one group or another who are going to be more interested than others. I do think it's something that's going to be broadly of appeal to people. And as I also mentioned, not to forget the fact that it has the benefit of being once daily, which again is an attractive part of a chronic medication. So as I said, we're as excited about the launch of vanza as we have been about any of our other CFTR modulators.

I was just trying to get a sense of the repetitive, like how quickly people might convert over is you're thinking. Do you think it'd be a kind of slow and steady or pretty rapid, your feedback there?

Yeah. I mean, certainly the reaction we've had from physicians and patients to the profile has been very enthusiastic. I'm not going to speculate exactly on how rapidly we're going to get transitions and people restarted, Liisa.

Liisa, maybe I'll just add one thing if you want to think through it. Patients with CF usually visit their doctors once a quarter. As Stuart said, the patients are very aware of drug development and Vanzacaftor in particular, as are their physicians. And patients have consistently expressed interest in thinking about medicines that may bring them the potential for higher efficacy. I think that that's as far as we can go with regard to timing, but maybe those are pieces of information that are helpful to you.

The next question will come from Michael Yee with Jeffries. Please go ahead.

Michael Yee

Hey, guys. Thank you. Great. Two questions for us. On the Alpine product, can you just remind me, I know you guys think it's best-in-class, but how to think about greater reduction in proteinuria versus say, a parent program that wants data in first half of ‘25. And is it your idea that you have greater reductions and therefore better stabilization of EGFR, or that it also will just be shining through in lupus and other autoimmune diseases for which we'll have to wait for RUBY-3 data? So just maybe talk about and remind us how you think the benefits will be seen on that product.

And then really quickly on the acute pain launch. Can you just remind me, on the comments on the No Pain Act, you believe you'll eventually get reimbursement there, but that's more of a CMS exposure population to take that in consideration. And for commercial, that's more about blocking and tackling on formularies and commercial plans. Thank you.

A - Reshma Kewalramani

Yeah. Mike, I'm going to ask Stuart to comment on No Pain first. I think it was a little hard to hear you, Mike, but I think Stuart, Mike's question is, does the No Pain Act pertain to government-paid patients, and how are you thinking about commercial? And then I'll come back for Pove.

Yeah. So No Pain Mike, is looking at the add-on payment to patients who are treated in the outpatient ambulatory surgical center setting. As you said, we were not listed as one of the products, but that is because we're not approved. And so yes, we do anticipate being added to that list once Suzetrigine is approved.

In terms of in the Medicare area, maybe you are also thinking of the alternatives to Pain Act, which is looking to level the playing field in terms of things like step therapy and not allowing things like that and utilization management in Part D, and also making sure that there is parity in terms of the co-pay for patients between opioids and non-opioids.

In terms of commercial, as you said, that these are less relevant to that. This is really, sort of as you said, blocking and tackling is what we'll be doing in talking to commercial plans.

And Mike, on the question on Pove, I think the question was, how should we think about Pove in IgA nephropathy, and then how should we think about it in the other studies? Is it all about proteinuria?

So, the way I would think about it is underlying cause of disease and B-cell mediated diseases. We have two Phase 2 studies going on. It was a very clever design by Alpine scientists. There's a RUBY-3, which is a basket of B-cell mediated renal diseases, IgA nephropathy, which is now going to Phase-3 this month. It has lupus nephritis in there, ANCA associated nephritis, as well as membranous. All of these diseases are B-cell mediated diseases.

In many of these diseases, proteinuria is important. But I'll tell you, for example, in membranous, PLA2R is a very important biomarker. And in some of the nephritides as you may know, hematuria is very, very important. So I think protein is – proteinuria is clearly very important in IgA nephropathy. And its prominence is elevated because of the FDA's acceptance of proteinuria in IgA nephropathy as an accelerated approval endpoint. But hematuria is important in some. Looking at biomarkers like PLA2R is important in others.

And in the RUBY-4 basket, these are B-cell mediated heme diseases. It's really not about proteinuria. It's about other markers of interest, like it could be something like hemoglobin or in the case of ITP, it would be platelets. But the way I would look at it and my enthusiasm for povetacicept is because it is such a good B-cell – it's such a good medicine to tamp down the B-cells, because it's dual inhibition and impacts maturation, proliferation and differentiation of B-cells, and that's where my optimism for B-cell mediated diseases comes from.

Next slide, Chuck. We'll wrap it there, please.

Thank you. This concludes our question-and-answer session, as well as our conference call for today. Thank you for attending today's presentation. A replay of today's event will be available shortly after the call concludes by dialing 1-877-344-7529 or 1-412-317-0088 using replay access code 101-86971.

Thank you for your participation. You may now disconnect.

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IMAGES

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Breech baby causes, what does it mean and how to turn a breech baby
Fetal Positions and Adaptations
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Labor and Birth Processes
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COMMENTS

Fetal Presentation, Position, and Lie (Including Breech Presentation
Fetal presentation: Fetal part that overlies the maternal pelvic inlet; vertex (cephalic), face, brow, breech, shoulder, funic (umbilical cord), or compound (more than one part, eg, shoulder and hand) Fetal position: Relation of the presenting part to an anatomic axis; for vertex presentation, occiput anterior, occiput posterior, occiput transverse Fetal lie: Relation of the fetus to the long ...
Breech Presentation
Breech Births. In the last weeks of pregnancy, a baby usually moves so his or her head is positioned to come out of the vagina first during birth. This is called a vertex presentation. A breech presentation occurs when the baby's buttocks, feet, or both are positioned to come out first during birth. This happens in 3-4% of full-term births.
Breech Presentation
Breech presentation refers to the fetus in the longitudinal lie with the buttocks or lower extremity entering the pelvis first. The three types of breech presentation include frank breech, complete breech, and incomplete breech. In a frank breech, the fetus has flexion of both hips, and the legs are straight with the feet near the fetal face, in a pike position. The complete breech has the ...
Fetal Presentation, Position, and Lie (Including Breech Presentation)
Presentation refers to the part of the fetus's body that leads the way out through the birth canal (called the presenting part). Usually, the head leads the way, but sometimes the buttocks (breech presentation), shoulder, or face leads the way.
If Your Baby Is Breech
A breech presentation occurs when the fetus's buttocks, feet, or both are in place to come out first during birth.
Fetal presentation before birth
Frank breech. When a baby's feet or buttocks are in place to come out first during birth, it's called a breech presentation. This happens in about 3% to 4% of babies close to the time of birth. The baby shown below is in a frank breech presentation. That's when the knees aren't bent, and the feet are close to the baby's head.
Breech: Types, Risk Factors, Treatment, Complications
Breech is when a fetus will be delivered buttocks or feet first. Learn of the risk factors, treatment methods, and complications.
Breech presentation
Breech presentation refers to the fetus in the longitudinal lie with the buttocks or lower extremity entering the pelvis first. Three types: Frank breech: fetus has flexion of both hips, and the legs are straight with the feet near the fetal face, in a pike position. Complete breech: fetus sits with flexion of both hips and both legs in a tuck ...
What Is the Vertex Position?
If your baby is still in the breech position at 36 weeks of pregnancy, your doctor may offer you an external cephalic version (ECV), which is where a doctor puts pressure on your uterus to try to ...
Breech Presentation: Types, Causes, Risks
Learn more about the types, causes, and risks of breech presentation, along with how breech babies are typically delivered.
PDF Management of breech presentation
The most widely quoted study regarding the management of breech presentation at term is the 'Term Breech Trial'. Published in 2000, this large, international multicenter randomised clinical trial compared a policy of planned vaginal delivery with planned caesarean section for selected breech presentations.
Delivery, Face and Brow Presentation
The term presentation describes the leading part of the fetus or the anatomical structure closest to the maternal pelvic inlet during labor. The presentation can roughly be divided into the following classifications: cephalic, breech, shoulder, and compound. Cephalic presentation is the most common and can be further subclassified as vertex, sinciput, brow, face, and chin. The most common ...
Fetal Position in the Womb
Fetal position mainly describes the angle of the baby to the birth canal, which can be cephalic or vertex, breech, or transverse. Learn more.
Fetal presentation: Breech, posterior, transverse lie, and more
Fetal presentation, or how your baby is situated in your womb at birth, is determined by the body part that's positioned to come out first, and it can affect the way you deliver. At the time of delivery, 97 percent of babies are head-down (cephalic presentation). But there are several other possibilities, including feet or bottom first (breech) as well as sideways (transverse lie) and diagonal ...
PDF Breech Presentation Fact Sheet
Norway 40%.13 Finland 39%.14 Findings: Less birth trauma for vaginal breech deliveries than vaginal vertex deliveries. More trauma for breech vaginal delivery than breech CS, but lower long-term morbidity for breech vaginal than breech cesarean deliveries. Breech vaginal death 0.07%, vertex vaginal delivery death 0.02%.
Breech birth
In the third period, from the 36th gestational week onward, the incidence of cephalic and breech presentations remain stable, i.e. breech presentation around 3-4% and cephalic presentation approximately 95%. In the general population, incidence of breech presentation at preterm corresponds to the incidence of breech presentation when birth ...
PDF Is breech presentation a risk factor for cerebral palsy? A Norwegian
Severity or subtype of CP did not differ between breech and vertex presentation. INTERPRETATION Breech delivery is a signiﬁcant risk factor for CP, in particular among singletons born by vaginal delivery at term.
Water aerobics as a means for the prenatal correction in ...
Download Citation | Water aerobics as a means for the prenatal correction in the case of breech presentation of the fetus | Background: The delivery of the fetus in breech presentation remains one ...
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Vertex Announces CASGEVY™ Reimbursement Agreement for the Treatment of
The Investor Relations website contains information about Vertex Pharmaceuticals's business for stockholders, potential investors, and financial analysts.
Fetal Presentation, Position, and Lie (Including Breech Presentation
Fetal presentation: Fetal part that overlies the maternal pelvic inlet; vertex (cephalic), face, brow, breech, shoulder, funic (umbilical cord), or compound (more than one part, eg, shoulder and hand) Fetal position: Relation of the presenting part to an anatomic axis; for transverse presentation, occiput anterior, occiput posterior, occiput transverse Fetal lie: Relation of the fetus to the ...
Vertex Pharmaceuticals, Inc. (VRTX) Q2 2024 Earnings Call Transcript
Vertex Pharmaceuticals, Inc. (NASDAQ:NASDAQ:VRTX) Q2 2024 Earnings Conference Call August 1, 2024 4:30 PM ETCompany ParticipantsReshma Kewalramani - Chief...
MOSMATIC Ltd. Moscow, Russia Solution Partner SIEMENS ...
MOSMATIC Ltd. Moscow, Russia Solution Partner SIEMENS Authorized Dialer RITTAL. ООО «МОСМАТИК». Benefits, Facility. -Engineering Programming Electrical Equipment Deliveries Low Voltage Compete Equipment Production. Our History and Experience.

Breech Births

What are the different types of breech birth presentations?

What causes a breech presentation?

How is a breech presentation diagnosed?

Can a breech presentation mean something is wrong?

Can a breech presentation be changed?

Medical Techniques

ECV will not be tried if:

Complications of EVC include:

Vaginal delivery versus cesarean for breech birth?

What are the risks and complications of a vaginal delivery?

When is a cesarean delivery used with a breech presentation?

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Episiotomy: Advantages & Complications

Retained Placenta

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Fetal Presentation, Position, and Lie (Including Breech Presentation)

Position and Presentation of the Fetus

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Occiput posterior position

Breech presentation

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If Your Baby Is Breech

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What Causes Breech Presentation?

What Is Breech Presentation?

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Breech, posterior, transverse lie: What position is my baby in?

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D.Sokoloff Moscow University & IZMIRAM , Moscow, Russia E.Yushkov, A.Lukin P.Frick, Russia